Basic Information
| Provider Information | |||||||||
| NPI: | 1912987306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30532 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325031532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 GULF BREEZE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325617809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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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 | 207X00000X | 30241 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD073529L | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | ME105667 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2698586 | 05 | OH | MEDICAID | 7998568 | 01 | AETNA | OTHER | 146QJ | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | P00807016 | 01 | MEDICARE RAILROAD | OTHER | 592-09123 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 1017642910001 | 05 | PA | MEDICAID | 592-09139 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 001853100 | 05 | FL | MEDICAID | 114534 | 05 | AL | MEDICAID | 115066 | 05 | AL | MEDICAID | 3810008259 | 05 | WV | MEDICAID | 881244 | 05 | AZ | MEDICAID |