=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023753779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIE BERNADINE SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2022
-----------------------------------------------------
Last Update Date | 04/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 234 SAN REMO BLVD
-----------------------------------------------------
City | NORTH LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-328-0375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 SAN REMO BLVD
-----------------------------------------------------
City | NORTH LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-328-0375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 11017650
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------