Basic Information
| Provider Information | |||||||||
| NPI: | 1164471397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 AUTOMATION WAY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805255737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702241670 | ||||||||
| FaxNumber: | 9702215206 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 BIGHORN RD | ||||||||
| Address2: | |||||||||
| City: | FT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805253480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702299800 | ||||||||
| FaxNumber: | 9702215406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 01/15/2010 | ||||||||
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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 | 207Q00000X | 17246 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01172469 | 05 | CO | MEDICAID |