Basic Information
| Provider Information | |||||||||
| NPI: | 1861574824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | PEARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., F.A.C.E.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291253 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974397398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419978412 | ||||||||
| FaxNumber: | 5419021695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00049058 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD22482 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 286469 | 05 | OR | MEDICAID | 8257354 | 05 | WA | MEDICAID |