MEDICARE: MR. STEPHEN GLEN 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	PA9101253	FL

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	:	1801015037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN GLEN SMITH PA-C

Provider Business Mailing Address
First Line	:	1462 SE GRIFFIN TER
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5414
Country	:	US
Telephone Number	:	772-337-0981
Fax Number	:	772-335-9941

Provider Business Practice Location Address
First Line	:	6501 S OCEAN DR
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-2041
Country	:	US
Telephone Number	:	772-468-4206
Fax Number	:	772-468-4270

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

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. STEPHEN GLEN SMITH PA-C” Practice Location

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