Provider Demographics
NPI:1679895668
Name:JEROME SMITH MD PC
Entity type:Organization
Organization Name:JEROME SMITH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:GLASCOE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-276-4266
Mailing Address - Street 1:909 HIOAKS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4038
Mailing Address - Country:US
Mailing Address - Phone:804-276-4266
Mailing Address - Fax:804-276-5828
Practice Address - Street 1:909 HIOAKS RD
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4038
Practice Address - Country:US
Practice Address - Phone:804-276-4266
Practice Address - Fax:804-276-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035708207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006046398Medicaid
VA006046398Medicaid