Basic Information
| Provider Information | |||||||||
| NPI: | 1841268497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076261236 | ||||||||
| FaxNumber: | 2076261549 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076261236 | ||||||||
| FaxNumber: | 2076261549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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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 | 1839 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 1839 | ME | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 410120099 | 05 | ME | MEDICAID |