=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376753277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENNEN D SMITH DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 10/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 ST FRANCIS DR
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56520-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-643-3000
-----------------------------------------------------
Fax | 218-643-0850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4784 AMBER VALLEY PKWY S CHI PROVIDER ENROLLMENT - FARGO DIVISON
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58104-8614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-237-8072
-----------------------------------------------------
Fax | 937-599-1730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 15379
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 34.010178
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 61204
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------