Basic Information
Provider Information | |||||||||
NPI: | 1780601518 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | R MACLEAN SMITH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALLERGY AND ASTHMA CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5126 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053351952 | ||||||||
FaxNumber: | 6053739971 | ||||||||
Practice Location | |||||||||
Address1: | 4301 W 57TH ST STE 160 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571082288 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053327000 | ||||||||
FaxNumber: | 6053325455 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 06/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | MACLEAN | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER AND OWNER | ||||||||
AuthorizedOfficialTelephone: | 6053327000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0201X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology |
ID Information
ID | Type | State | Issuer | Description | 0006932 | 01 | SD | BCBS GROUP | OTHER | 90741LA | 01 | MN | BCBS GROUP | OTHER |