Basic Information
| Provider Information | |||||||||
| NPI: | 1003810581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 QUARRIER ST | ||||||||
| Address2: | STE 301 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253012313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434625 | ||||||||
| FaxNumber: | 3043434626 | ||||||||
| Practice Location | |||||||||
| Address1: | 416 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253091456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047667141 | ||||||||
| FaxNumber: | 3047667143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 14970 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0120020000 | 05 | WV | MEDICAID |