Basic Information
| Provider Information | |||||||||
| NPI: | 1720005325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | SUITE 130 - PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175475345 | ||||||||
| FaxNumber: | 3179624343 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124422500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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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 | 207P00000X | 01033441A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 4301042616 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100388340 | 05 | IN | MEDICAID | 930040138 | 01 | IN | RAILROAD MEDICARE | OTHER |