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General NPI Number Information
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NPI Number | 1124253521
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Entity Type | Individual
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Provider Name | JEREMY K SMALLWOOD RPA/RA, RT(R)(VI)
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Gender | Male
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Dates
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Enumeration Date | 05/28/2009
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Last Update Date | 05/28/2009
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Provider Practice Location Address
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Address Line | 3109 BIENVILLE BLVD
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City | OCEAN SPRINGS
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State | MS
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Zip | 39564-4361
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Country | US
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Telephone | 228-818-1117
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Fax | 228-818-6090
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Provider Business Mailing Address
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Address Line | 3109 BIENVILLE BLVD
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City | OCEAN SPRINGS
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State | MS
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Zip | 39564-4361
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Country | US
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Telephone | 228-818-1117
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Fax | 228-818-6090
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 243U00000X
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Taxonomy Name | Radiology Practitioner Assistant
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License Number |
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 2471V0106X
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Taxonomy Name | Vascular-Interventional Technology Radiologic Technologist
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License Number |
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License Number State | MS
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