Healthcare Provider Details

I. General information

NPI: 1588276992
Provider Name (Legal Business Name): ERIC SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 W SUNGLADE DR
TUCSON AZ
85742-1134
US

IV. Provider business mailing address

1305 N MARTIN AVE
TUCSON AZ
85721-0001
US

V. Phone/Fax

Practice location:
  • Phone: 520-508-0382
  • Fax:
Mailing address:
  • Phone: 520-626-6154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN20016
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: