=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275732638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY SMITH MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2007
-----------------------------------------------------
Last Update Date | 02/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1033 BASIN AVE
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58504-6649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-223-6613
-----------------------------------------------------
Fax | 701-221-9114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1033 BASIN AVE
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58504-6649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-223-6613
-----------------------------------------------------
Fax | 701-221-9114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INS/BILLING
-----------------------------------------------------
Name | DANITA DEICHERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-223-6613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------