Provider Demographics
NPI:1952537011
Name:GREGORY W. SMITH MD PA
Entity Type:Organization
Organization Name:GREGORY W. SMITH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LIDBOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-465-1091
Mailing Address - Street 1:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78296-1768
Mailing Address - Country:US
Mailing Address - Phone:956-542-1850
Mailing Address - Fax:956-542-2879
Practice Address - Street 1:1090 EAST ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3822
Practice Address - Country:US
Practice Address - Phone:956-542-1850
Practice Address - Fax:956-542-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5700207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207043501Medicaid
TX0040SMOtherBLUE CROSS BLUE SHIELD
TXDP8222OtherMEDICARE - RAIL ROAD
TX0040SMOtherBLUE CROSS BLUE SHIELD
TX0040SMOtherBLUE CROSS BLUE SHIELD