Basic Information
| Provider Information | |||||||||
| NPI: | 1609802867 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLIVIA SMITH-BLACKWELL MD PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEADOW FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7163323525 | ||||||||
| Practice Location | |||||||||
| Address1: | 533 MEADOW DR | ||||||||
| Address2: | #2 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166934600 | ||||||||
| FaxNumber: | 7166934807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 01/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITH-BLACKWELL | ||||||||
| AuthorizedOfficialFirstName: | OLIVIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7166934600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02632800 | 05 | NY | MEDICAID |