MEDICARE: CHARLOTTE SMITH B.A.

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	390200000X	Student in an Organized Health Care Education/Training Program	00000	OK

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	:	1528435922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE SMITH B.A.

Provider Business Mailing Address
First Line	:	PO BOX 702504
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74170-2504
Country	:	US
Telephone Number	:	918-791-0026
Fax Number	:	918-791-0043

Provider Business Practice Location Address
First Line	:	4122 W 55TH PL
Second Line	:	SUITES 207/208
City	:	TULSA
State	:	OK
Zip	:	74107-9108
Country	:	US
Telephone Number	:	918-791-0026
Fax Number	:	918-791-0043

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

Provider Enumeration Date	:	09/01/2015
Last Update Date	:	09/01/2015

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Directions to “ CHARLOTTE SMITH B.A.” Practice Location

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