Provider Demographics
NPI:1053093559
Name:SMITH, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HOPI DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-4931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 N THOMPSON LN
Practice Address - Street 2:
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-9305
Practice Address - Country:US
Practice Address - Phone:724-864-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064755363AM0700X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical