MEDICARE: SMART FORM INC

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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033102330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMART FORM INC

Provider Business Mailing Address
First Line	:	100 5TH AVE
Second Line	:	SUITE 804
City	:	PITTSBURGH
State	:	PA
Zip	:	15222-1821
Country	:	US
Telephone Number	:	412-281-9913
Fax Number	:	412-281-8074

Provider Business Practice Location Address
First Line	:	100 5TH AVE
Second Line	:	SUITE 804
City	:	PITTSBURGH
State	:	PA
Zip	:	15222-1821
Country	:	US
Telephone Number	:	412-281-9913
Fax Number	:	412-281-8074

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MRS. LAURIE J CHURMA
Credential	:	BOC CERTIFIED
Telephone Number	:	412-281-9913

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	08/22/2020

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Directions to “SMART FORM INC ” Practice Location

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