Basic Information
| Provider Information | |||||||||
| NPI: | 1578600623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MOON | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500-6355 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104977520 | ||||||||
| FaxNumber: | 6104977525 | ||||||||
| Practice Location | |||||||||
| Address1: | 1560 GARRETT RD | ||||||||
| Address2: | |||||||||
| City: | UPPER DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190824505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102843300 | ||||||||
| FaxNumber: | 6102843706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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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 | 367A00000X | MW008272L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 001250948 | 05 | PA | MEDICAID |