Provider Demographics
NPI:1447550926
Name:TIMOTHY W SMITH DO LLC
Entity type:Organization
Organization Name:TIMOTHY W SMITH DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:513-742-1777
Mailing Address - Street 1:289 NORTHLAND BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3679
Mailing Address - Country:US
Mailing Address - Phone:513-742-1777
Mailing Address - Fax:888-577-7659
Practice Address - Street 1:289 NORTHLAND BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3679
Practice Address - Country:US
Practice Address - Phone:513-742-1777
Practice Address - Fax:888-577-7659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004608261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0713768Medicaid
OHSM0637965OtherMEDICARE
OHSM0637965OtherMEDICARE