Basic Information
| Provider Information | |||||||||
| NPI: | 1265457253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | BRADBURY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 VT ROUTE 12 | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050918172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024574809 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 32 PLEASANT STREET | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024573030 | ||||||||
| FaxNumber: | 8024572157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 042-0007558 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0009064 | 05 | VT | MEDICAID |