Healthcare Provider Details

I. General information

NPI: 1437110939
Provider Name (Legal Business Name): JACK E SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 CENTRE AVE SUITE 510
PITTSBURGH PA
15206-3721
US

IV. Provider business mailing address

5750 CENTRE AVE SUITE 510
PITTSBURGH PA
15206-3709
US

V. Phone/Fax

Practice location:
  • Phone: 412-924-1100
  • Fax: 412-924-1111
Mailing address:
  • Phone: 412-924-1100
  • Fax: 412-924-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD034721E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: