Provider Demographics
NPI:1841948502
Name:SMITH, PEACHES
Entity type:Individual
Prefix:MISS
First Name:PEACHES
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 1:6621 HASBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-4648
Mailing Address - Country:US
Mailing Address - Phone:215-455-0536
Mailing Address - Fax:215-455-0536
Practice Address - Street 1:6621 HASBROOK AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19111-4648
Practice Address - Country:US
Practice Address - Phone:215-455-0536
Practice Address - Fax:215-455-0536
Is Sole Proprietor?:No
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA127679207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPA127679OtherEMT