Basic Information
| Provider Information | |||||||||
| NPI: | 1043314214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | HERMON | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 WYMAN PARK DRIVE | ||||||||
| Address2: | SUITE 359A | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103383016 | ||||||||
| FaxNumber: | 4103383420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E EAGER STREET | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105229800 | ||||||||
| FaxNumber: | 4105229872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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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 | 208000000X | D36633 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 525891000 | 05 | MD | MEDICAID |