Basic Information
| Provider Information | |||||||||
| NPI: | 1912916479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | #540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 S. NATIONAL AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172697728 | ||||||||
| FaxNumber: | 4172697729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/21/2013 | ||||||||
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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 | 207R00000X | E-3423 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 18409 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2006024382 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 148194001 | 05 | AR | MEDICAID | 211845 | 01 | BLUE CROSS OF MO | OTHER | 203628904 | 05 | MO | MEDICAID |