Basic Information
| Provider Information | |||||||||
| NPI: | 1982689816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMYTH | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55769 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392965769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012006162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 969 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774062916 | ||||||||
| FaxNumber: | 6016827909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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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 | 2085R0202X | ME66015 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 19681 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 375498700 | 05 | FL | MEDICAID | 06550800 | 05 | MS | MEDICAID |