MEDICARE: TARA ROSE SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZA2600X	Medical Art Specialist/Technologist	220311	NY

General Provider Information

NPI Number	:	1083322325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA ROSE SMITH

Provider Business Mailing Address
First Line	:	11 W MAIN ST # 5-313
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-3087
Country	:	US
Telephone Number	:	860-373-6289
Fax Number	:	860-373-6289

Provider Business Practice Location Address
First Line	:	120 W MAIN ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8314
Country	:	US
Telephone Number	:	860-373-6289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2022
Last Update Date	:	11/07/2022

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Directions to “ TARA ROSE SMITH ” Practice Location

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