MEDICARE: MARY D SMITH

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	332B00000X	Durable Medical Equipment & Medical Supplies	MG00141	AR

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	:	1366630907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY D SMITH

Provider Business Mailing Address
First Line	:	313 PLAZA
Second Line	:
City	:	WEST HELENA
State	:	AR
Zip	:	72390-2453
Country	:	US
Telephone Number	:	870-572-2792
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 PLAZA
Second Line	:
City	:	WEST HELENA
State	:	AR
Zip	:	72390-2453
Country	:	US
Telephone Number	:	870-572-2792
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARY DEAN SMITH
Credential	:
Telephone Number	:	870-572-2791

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	02/22/2010

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