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General NPI Number Information
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NPI Number | 1891993713
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Entity Type | Organization
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Legal Business Name | SMITH CLINIC P A
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Dates
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Enumeration Date | 07/03/2007
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Last Update Date | 02/21/2008
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Provider Practice Location Address
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Address Line | 3669 ELLENDALE CIR
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City | AMMON
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State | ID
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Zip | 83406-4749
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Country | US
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Telephone | 208-521-5936
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Fax | 208-524-5608
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Provider Business Mailing Address
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Address Line | 3669 ELLENDALE CIRCLE
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City | IDAHO FALLS
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State | ID
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Zip | 83406
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Country | US
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Telephone | 208-521-5936
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Fax | 208-524-5608
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Authorized Official
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Title or Position | OWNER
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Name | DR. OLIVER D SMITH
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Credential | M.D.
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Telephone | 208-521-5936
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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 |
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License Number State | ID
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