Basic Information
| Provider Information | |||||||||
| NPI: | 1568445427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 110 W SQUANTUM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173763000 | ||||||||
| FaxNumber: | 6177741905 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W SQUANTUM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173763000 | ||||||||
| FaxNumber: | 6177741905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 58595 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 058595 | 01 | MA | TUFTS MEDICARE PREFERRED | OTHER | 0016428 | 01 | MA | NEIGHBORHOOD HLTH PLAN | OTHER | 042297845 | 01 | MA | HCVM | OTHER | 042297845 | 01 | MA | TRICARE | OTHER | 042297845 | 01 | MA | DOC FIRST | OTHER | 4219050 | 01 | MA | AETNA | OTHER | 042297845 | 01 | MA | PRIVATE HEALTHCARE SYSTEM | OTHER | 042297845 | 01 | MA | UNITED HEALTH CARE | OTHER | 058595 | 01 | MA | TUFTS | OTHER | 3026191 | 05 | MA | MEDICAID | B10355401 | 01 | MA | CIGNA | OTHER | J07003 | 01 | MA | BCBS | OTHER | 042297845 | 01 | MA | GREAT WEST HEALTH CARE | OTHER | 62309 | 01 | MA | HVD PILGRIM HEALTH CARE | OTHER |