MEDICARE: MRS. EILEEN MARY SMITH RN BSN

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	163WD0400X	Diabetes Educator Registered Nurse	551537	NY

General Provider Information

NPI Number	:	1063058576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EILEEN MARY SMITH RN BSN

Provider Business Mailing Address
First Line	:	103 W MAIN ST
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-3003
Country	:	US
Telephone Number	:	631-901-2138
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 W MAIN ST
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-3003
Country	:	US
Telephone Number	:	631-687-4188
Fax Number	:

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

Provider Enumeration Date	:	11/19/2019
Last Update Date	:	09/11/2025

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