Basic Information
| Provider Information | |||||||||
| NPI: | 1619926250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 LUSK DR | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648508855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174512060 | ||||||||
| FaxNumber: | 4174516214 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 LUSK DR | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174512060 | ||||||||
| FaxNumber: | 4174516214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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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 | 2001008549 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 245312202 | 05 | MO | MEDICAID |