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General NPI Number Information
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NPI Number | 1184705980
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Entity Type | Individual
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Provider Name | SHANE MICHAEL SMITH M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 06/17/2021
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Provider Practice Location Address
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Address Line | 516 W 14TH AVE STE 100
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City | HOLDREGE
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State | NE
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Zip | 68949-1215
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Country | US
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Telephone | 308-995-4431
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Fax | 308-995-3247
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Provider Business Mailing Address
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Address Line | PO BOX 5074
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City | SIOUX FALLS
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State | SD
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Zip | 57117-5074
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Country | US
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Telephone |
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 37886
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 24107
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License Number State | NE
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