Provider Demographics
NPI:1356519128
Name:TIM M SMITH, M.D.
Entity type:Organization
Organization Name:TIM M SMITH, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:850-763-3722
Mailing Address - Street 1:100 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7608
Mailing Address - Country:US
Mailing Address - Phone:850-763-3722
Mailing Address - Fax:850-785-7393
Practice Address - Street 1:100 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7608
Practice Address - Country:US
Practice Address - Phone:850-763-3722
Practice Address - Fax:850-785-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME8816208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50715Medicare UPIN
FLK0708Medicare PIN