MEDICARE: STEPHEN 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	390200000X	Student in an Organized Health Care Education/Training Program	2255A2300X	PA

General Provider Information

NPI Number	:	1942600044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN SMITH

Provider Business Mailing Address
First Line	:	6504 WALNUT PARK DR
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-1032
Country	:	US
Telephone Number	:	267-283-5571
Fax Number	:

Provider Business Practice Location Address
First Line	:	6504 WALNUT PARK DR
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-1032
Country	:	US
Telephone Number	:	267-283-5571
Fax Number	:

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

Provider Enumeration Date	:	08/26/2014
Last Update Date	:	08/26/2014

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Directions to “ STEPHEN SMITH ” Practice Location

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