Provider Demographics
NPI:1609064658
Name:BRENDA C. SMITH M.D., INC.
Entity type:Organization
Organization Name:BRENDA C. SMITH M.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-799-4437
Mailing Address - Street 1:PO BOX 93457
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-3457
Mailing Address - Country:US
Mailing Address - Phone:626-799-4437
Mailing Address - Fax:626-441-6300
Practice Address - Street 1:1800 FAIR OAKS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4776
Practice Address - Country:US
Practice Address - Phone:626-799-4437
Practice Address - Fax:626-441-6300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47927174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22299Medicare PIN
CAA92776Medicare UPIN