MEDICARE: KERRY-ANN KEISHA SMITH RDMS

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	156F00000X	Technician/Technologist	133816	NY

General Provider Information

NPI Number	:	1912496746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY-ANN KEISHA SMITH RDMS

Provider Business Mailing Address
First Line	:	230 BEACH 102ND ST STE 2B
Second Line	:
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2871
Country	:	US
Telephone Number	:	347-497-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 BEACH 102ND ST STE 2B
Second Line	:
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2871
Country	:	US
Telephone Number	:	347-497-6200
Fax Number	:

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

Provider Enumeration Date	:	05/07/2018
Last Update Date	:	05/07/2018

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