MEDICARE: MRS. GRETCHEN LEE SMITH PA-C

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	363A00000X	Physician Assistant	C0002171	MD

General Provider Information

NPI Number	:	1619976149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRETCHEN LEE SMITH PA-C

Provider Business Mailing Address
First Line	:	1650 UNION AVE
Second Line	:	PBG EMPLOYEE HEALTH & WELLNESS CENTER
City	:	BALTIMORE
State	:	MD
Zip	:	21211-1917
Country	:	US
Telephone Number	:	410-554-7874
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 UNION AVE
Second Line	:	PBG EMPLOYEE HEALTH & WELLNESS CENTER
City	:	BALTIMORE
State	:	MD
Zip	:	21211-1917
Country	:	US
Telephone Number	:	410-554-7874
Fax Number	:

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/08/2007

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