MEDICARE: DR. BRENDAN JAMES SMYTH PHD/ MD

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	207R00000X	Internal Medicine Physician	036.114418	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036.114418	OTHER	IL	IL STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1528465820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENDAN JAMES SMYTH PHD/ MD

Provider Business Mailing Address
First Line	:	4025 FLORA PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-3603
Country	:	US
Telephone Number	:	610-209-8740
Fax Number	:

Provider Business Practice Location Address
First Line	:	311 PENNINGTON ROCKY HILL RD
Second Line	:
City	:	PENNINGTON
State	:	NJ
Zip	:	08534-2130
Country	:	US
Telephone Number	:	609-818-4824
Fax Number	:

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

Provider Enumeration Date	:	12/02/2014
Last Update Date	:	12/02/2014

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