Healthcare Provider Details

I. General information

NPI: 1467717116
Provider Name (Legal Business Name): SMITH MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE MOB EAST #450
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

100 E LANCASTER AVE MOB EAST #450
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 610-896-0648
  • Fax: 610-642-1690
Mailing address:
  • Phone: 610-896-0648
  • Fax: 610-642-1690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD427776
License Number StatePA

VIII. Authorized Official

Name: DR. BRADLEY JASON SMITH
Title or Position: VICE-PRESIDENT
Credential: M.D.
Phone: 215-668-4613