MEDICARE: DR. HENRY THOMAS SMITH M.D.

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	207VG0400X	Gynecology Physician	5592A	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	303832	OTHER	WY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1104822972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY THOMAS SMITH M.D.

Provider Business Mailing Address
First Line	:	PO BOX 8760
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83002-8760
Country	:	US
Telephone Number	:	307-733-1122
Fax Number	:	307-734-9577

Provider Business Practice Location Address
First Line	:	230 EAST BROADWAY
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001
Country	:	US
Telephone Number	:	307-733-1122
Fax Number	:	307-734-9577

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	07/08/2007

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