Provider Demographics
NPI:1063574903
Name:SMITH, JEREMY TAYLOR (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TAYLOR
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 CENTRE STREET
Mailing Address - Street 2:SUITE 56, FAULKNER HOSPITAL
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-983-7295
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE STREET
Practice Address - Street 2:SUITE 56, FAULKNER HOSPITAL
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-983-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228179207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA246799OtherMA STATE LICENSE
MA228179OtherLIMITED LICENSE