Healthcare Provider Details

I. General information

NPI: 1730456880
Provider Name (Legal Business Name): JOSH BRIAN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 ANAMARIA DR
RAPID CITY SD
57701-7366
US

IV. Provider business mailing address

13510 EARL CT
RAPID CITY SD
57702-7406
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-4700
  • Fax: 605-721-4708
Mailing address:
  • Phone: 586-596-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704267742
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCR000872
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: