Basic Information
| Provider Information | |||||||||
| NPI: | 1598788101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JACKSON BRUCE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 S 9TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076810 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 S 9TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558430 | ||||||||
| FaxNumber: | 2159235828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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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 | 207R00000X | MD008957E | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | MD008957E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1940805 | 05 | NJ | MEDICAID | 000793625 | 05 | PA | MEDICAID |