Basic Information
| Provider Information | |||||||||
| NPI: | 1285934604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARYBETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAUMBERGER | ||||||||
| OtherFirstName: | MARYBETH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10724 STATE ROUTE 212 NE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446128740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308747165 | ||||||||
| FaxNumber: | 3308747166 | ||||||||
| Practice Location | |||||||||
| Address1: | 10724 STATE ROUTE 212 NE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446128740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308747165 | ||||||||
| FaxNumber: | 3308747166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11140 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0127945 | 05 | OH | MEDICAID |