Basic Information
| Provider Information | |||||||||
| NPI: | 1922072941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | JAMES | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8600 NICOLLET AVE S | ||||||||
| Address2: | 31500A | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554202824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528876600 | ||||||||
| FaxNumber: | 9528867015 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 NICOLLET AVE S | ||||||||
| Address2: | MAIL STOP 31500A | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554202824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528876600 | ||||||||
| FaxNumber: | 9528867015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/22/2008 | ||||||||
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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 | 20246 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 431582100 | 05 | MN | MEDICAID |