Healthcare Provider Details

I. General information

NPI: 1760434534
Provider Name (Legal Business Name): CASS R SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST SUITE 316
BOISE ID
83712-6267
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7011
  • Fax: 208-381-7216
Mailing address:
  • Phone: 208-381-7310
  • Fax: 208-381-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberM9941
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: