Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 01060132A | IN |
NPI | 1124050851 |
---|---|
Provider Name | Dr. Stephen M. Smith |
First Address | South Bend, IN 46617-1924 |
Second Address | South Bend, IN 46601-1156 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 05/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200511880 | (05) | IN |
I12726 | (02) | IN |
M400033274 | MEDICARE PTAN (01) | IN |