Basic Information
| Provider Information | |||||||||
| NPI: | 1871633107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | RENEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 N BROAD ST | ||||||||
| Address2: | 3RD FLR CARDIOLOGY CONSULTANTS OF PHILA PC | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154627100 | ||||||||
| FaxNumber: | 2154633820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | POB I SUITE 400 | ||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108762400 | ||||||||
| FaxNumber: | 6108764308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA001153L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103198302 0001 | 05 | PA | MEDICAID |