Basic Information
| Provider Information | |||||||||
| NPI: | 1487743159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604420711 | ||||||||
| FaxNumber: | 8604443733 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604420711 | ||||||||
| FaxNumber: | 8604443733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 025823 | CT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 4041679 | 05 | CT | MEDICAID | 4024972 | 05 | CT | MEDICAID |