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NPI Code Detail

MEDICARE: MS. MELISSA ANN SMOOT PAC, MPAS

MEDICARE: MS. MELISSA ANN SMOOT PAC, MPAS
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
1363AM0700XMedical Physician AssistantIL

General Provider Information

NPI Number : 1215902549
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MELISSA ANN SMOOT PAC, MPAS
Provider Business Mailing Address
First Line : 910 S VIRGINIA AVE
Second Line :
City : MARION
State : IL
Zip : 62959-3256
Country : US
Telephone Number : 618-993-3186
Fax Number :
Provider Business Practice Location Address
First Line : 2401 W MAIN ST
Second Line :
City : MARION
State : IL
Zip : 62959-1188
Country : US
Telephone Number : 618-997-5311
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/21/2006
Last Update Date : 07/08/2007

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