MEDICARE: ROBERT SMITH IV

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1467087767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT SMITH IV

Provider Business Mailing Address
First Line	:	PO BOX 60441
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32906-0441
Country	:	US
Telephone Number	:	321-317-8005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 SANTA MARIA PL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-1446
Country	:	US
Telephone Number	:	321-317-8005
Fax Number	:

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

Provider Enumeration Date	:	03/06/2020
Last Update Date	:	03/06/2020

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