MEDICARE: PHYLLIS SMITH

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	172A00000X	Driver
2	376J00000X	Homemaker

General Provider Information

NPI Number	:	1841894193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS SMITH

Provider Business Mailing Address
First Line	:	4685 PANHANDLE RD
Second Line	:
City	:	NEW VIENNA
State	:	OH
Zip	:	45159-9415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4685 PANHANDLE RD
Second Line	:
City	:	NEW VIENNA
State	:	OH
Zip	:	45159-9415
Country	:	US
Telephone Number	:	937-728-9589
Fax Number	:

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

Provider Enumeration Date	:	11/27/2020
Last Update Date	:	11/27/2020

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Directions to “ PHYLLIS SMITH ” Practice Location

Language	Start Address	Practice Location

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