Basic Information
| Provider Information | |||||||||
| NPI: | 1861433542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | JEROME | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PLEASANT VIEW | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371468136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157464711 | ||||||||
| FaxNumber: | 6152960952 | ||||||||
| Practice Location | |||||||||
| Address1: | 8333 9TH AVE | ||||||||
| Address2: | STE: G | ||||||||
| City: | PORT ARTHUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774628151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097298088 | ||||||||
| FaxNumber: | 4097298089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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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 | 207RH0003X | K1065 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | K1065 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | E76494 | 01 | TX | UPIN | OTHER | 122250702 | 05 | TX | MEDICAID |