Provider Demographics
NPI:1457749673
Name:SMITH, S
Entity Type:Individual
Prefix:
First Name:S
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1873
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44258-1873
Mailing Address - Country:US
Mailing Address - Phone:216-369-7119
Mailing Address - Fax:
Practice Address - Street 1:9701 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-4753
Practice Address - Country:US
Practice Address - Phone:216-369-7119
Practice Address - Fax:216-920-9973
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4545373H00000X
OHPN.157757164W00000X
251J00000X, 251E00000X
OHSC.7149156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No251J00000XAgenciesNursing Care
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082317Medicaid