MEDICARE: MATTHEW JAMES 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	1041C0700X	Clinical Social Worker	S.1701771	OH

General Provider Information

NPI Number	:	1568063469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW JAMES SMITH

Provider Business Mailing Address
First Line	:	24799 PURCELL RD
Second Line	:
City	:	SOUTH BLOOMINGVILLE
State	:	OH
Zip	:	43152-9740
Country	:	US
Telephone Number	:	614-302-2866
Fax Number	:

Provider Business Practice Location Address
First Line	:	24799 PURCELL RD
Second Line	:
City	:	SOUTH BLOOMINGVILLE
State	:	OH
Zip	:	43152-9740
Country	:	US
Telephone Number	:	614-302-2866
Fax Number	:

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

Provider Enumeration Date	:	11/06/2020
Last Update Date	:	11/06/2020

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