Basic Information
| Provider Information | |||||||||
| NPI: | 1003893322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 HOSPITAL DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | BENNINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 052015009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024475519 | ||||||||
| FaxNumber: | 8024475657 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 KENYON AVE | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017828000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 042212 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0420013392 | VT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | MD09423 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1026765 | 05 | VT | MEDICAID | U400473648 | 01 | RI | MEDICARE | OTHER |