1861409260 NPI number — ROY M SMITH PT

Table of content: ROY M SMITH PT (NPI 1861409260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861409260 NPI number — ROY M SMITH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
ROY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861409260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 BLYTHE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28203-5814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-355-4370
Provider Business Mailing Address Fax Number:
704-355-4231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 EAST BLVD
Provider Second Line Business Practice Location Address:
B#2
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28203-6103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-355-8100
Provider Business Practice Location Address Fax Number:
704-355-8127
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3108 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07924 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 110441 . This is a "WELLNESS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 294088 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 88728 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7211859 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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