Basic Information
| Provider Information | |||||||||
| NPI: | 1215111679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEPHEN D SMITH MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2825 FORT MISSOULA RD | ||||||||
| Address2: | 115 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598047420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067284292 | ||||||||
| FaxNumber: | 4067285770 | ||||||||
| Practice Location | |||||||||
| Address1: | 2825 FORT MISSOULA RD | ||||||||
| Address2: | 115 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598047420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067284292 | ||||||||
| FaxNumber: | 4067285770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 01/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHAPLA | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4067284292 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 4309 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0043563 | 05 | MT | MEDICAID |