Basic Information
| Provider Information | |||||||||
| NPI: | 1609825959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2644 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352022644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053221808 | ||||||||
| FaxNumber: | 2053221851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 HIGHWAY DR | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362031951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562412230 | ||||||||
| FaxNumber: | 2562412235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 11/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1-049134 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 51504038 | 01 | AL | BLUE SHIELD | OTHER | 051504038 | 05 | AL | MEDICAID | 430074751 | 01 | AL | PALMETTO GBA | OTHER |