Basic Information
| Provider Information | |||||||||
| NPI: | 1245205582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMIRICKY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 EAST BARNETT RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895250 | ||||||||
| FaxNumber: | 5417895538 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414727000 | ||||||||
| FaxNumber: | 3128292024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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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 | 036097740 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036097740 | 05 | IL | MEDICAID |