=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710114228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRY G SMITH MD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2009
-----------------------------------------------------
Last Update Date | 06/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67-1123 MAMALAHOA HWY SUITE 120
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-8451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-885-5236
-----------------------------------------------------
Fax | 808-885-4126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2650
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-885-5236
-----------------------------------------------------
Fax | 808-885-4126
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TERRY GLEN SMITH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-639-8811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 6367
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------