MEDICARE: MARK RANDALL SMITH PHD

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	103T00000X	Psychologist	LP2907	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	24981	OTHER		HEALTH PARTNERS
2	6120057	OTHER		UNITED BEH HEALTH
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0004049	OTHER		AETNA
5	112964	OTHER		CHOICE PLUS
6	030701079	OTHER		PRIME WEST HEALTH SYST
7	990991000146	OTHER		PREFERRED ONE/BHP
8	53308SM	OTHER	MN	BC
9	98520	OTHER	IA	BC
10	115129	OTHER	MN	UCARE

General Provider Information

NPI Number	:	1790779775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK RANDALL SMITH PHD

Provider Business Mailing Address
First Line	:	904 HWY 15 SOUTH FRONTAGE RD.
Second Line	:	SUITE H
City	:	HUTCHINSON
State	:	MN
Zip	:	55350
Country	:	US
Telephone Number	:	320-587-2939
Fax Number	:	320-864-1927

Provider Business Practice Location Address
First Line	:	904 HWY 15 SOUTH FRONTAGE RD.
Second Line	:	SUITE H
City	:	HUTCHINSON
State	:	MN
Zip	:	55350
Country	:	US
Telephone Number	:	320-587-2939
Fax Number	:	320-864-1927

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	10/30/2008

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Directions to “ MARK RANDALL SMITH PHD” Practice Location

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