MEDICARE: DR. REVONNA JOY SMITH DO

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	207L00000X	Anesthesiology Physician	34004618	OH

General Provider Information

NPI Number	:	1215908918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REVONNA JOY SMITH DO

Provider Business Mailing Address
First Line	:	104 PAWLEYS PLANTATION COURT
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45385
Country	:	US
Telephone Number	:	937-374-3625
Fax Number	:

Provider Business Practice Location Address
First Line	:	3180 KETTERING BLVD.1141 N MONROE DRIVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-297-6072
Fax Number	:	937-293-0969

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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