Healthcare Provider Details

I. General information

NPI: 1265571954
Provider Name (Legal Business Name): ALAN EDWARD SMITH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W 5TH ST
SHERIDAN WY
82801-2705
US

IV. Provider business mailing address

PO BOX 767
SHERIDAN WY
82801-0767
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-1000
  • Fax:
Mailing address:
  • Phone: 307-674-5123
  • Fax: 307-674-5230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number7044A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: