MEDICARE: MR. GLENNIS DALE SMITH P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA709	AL

General Provider Information

NPI Number	:	1023337037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLENNIS DALE SMITH P.A.

Provider Business Mailing Address
First Line	:	20 SCOTTSDALE DR
Second Line	:
City	:	ALABASTER
State	:	AL
Zip	:	35007-8994
Country	:	US
Telephone Number	:	205-685-9777
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 57TH ST N
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35217-3328
Country	:	US
Telephone Number	:	205-808-3220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2010
Last Update Date	:	06/01/2010

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