Basic Information
| Provider Information | |||||||||
| NPI: | 1710958681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | EDDIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13609 CARROLLTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233143214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572388751 | ||||||||
| FaxNumber: | 7572388750 | ||||||||
| Practice Location | |||||||||
| Address1: | 13609 CARROLLTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233143214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572388751 | ||||||||
| FaxNumber: | 7572388750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 10/21/2013 | ||||||||
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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 | 0101047898 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0574N | 01 | NC | NC BC BS | OTHER | 2180466 | 01 | VA | UHC/MAMSI | OTHER | 790574N | 05 | NC | MEDICAID | PAR | 01 | VA | AETNA | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | 005612748 | 05 | VA | MEDICAID | 005615577 | 05 | VA | MEDICAID | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY | OTHER | -002 -003 | 01 | VA | TRICARE/CHAMPUS | OTHER | PAR | 01 | VA | CIGNA | OTHER | 434846 | 01 | VA | ANTHEM BC/BS HEALTHKEEPER | OTHER | 21017 | 01 | VA | SENTARA/OPTIMA | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER |