Basic Information
| Provider Information | |||||||||
| NPI: | 1982654257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2825 FORT MISSOULA RD | ||||||||
| Address2: | #115 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598047420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067284292 | ||||||||
| FaxNumber: | 4067285770 | ||||||||
| Practice Location | |||||||||
| Address1: | 2825 FORT MISSOULA RD | ||||||||
| Address2: | #115 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598047420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067284292 | ||||||||
| FaxNumber: | 4067285770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4309 | MT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0043563 | 05 | MT | MEDICAID |