Basic Information
| Provider Information | |||||||||
| NPI: | 1508937723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68278 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350313370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054294151 | ||||||||
| FaxNumber: | 2054293378 | ||||||||
| Practice Location | |||||||||
| Address1: | 68278 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350313370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054294151 | ||||||||
| FaxNumber: | 2054294604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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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 | 10508 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009959550 | 05 | AL | MEDICAID | 009975215 | 05 | AL | MEDICAID |