Provider Demographics
NPI:1912977471
Name:SMITH, GARY CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2001 WATERDAM PLAZA DR
Mailing Address - Street 2:STE 105
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5416
Mailing Address - Country:US
Mailing Address - Phone:724-942-6499
Mailing Address - Fax:724-942-6498
Practice Address - Street 1:2001 WATERDAM PLAZA DR
Practice Address - Street 2:STE 105
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-5416
Practice Address - Country:US
Practice Address - Phone:724-942-6499
Practice Address - Fax:724-942-6498
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065711L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA012804Medicare PIN
G76023Medicare UPIN