Provider Demographics
NPI:1073698619
Name:SMITH, BRECKINRIDGE SIEVERS II
Entity type:Individual
Prefix:MR
First Name:BRECKINRIDGE
Middle Name:SIEVERS
Last Name:SMITH
Suffix:II
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BRECK
Other - Middle Name:SIEVERS
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:399 SEDGEWICK DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-3203
Mailing Address - Country:US
Mailing Address - Phone:302-697-6961
Mailing Address - Fax:
Practice Address - Street 1:KENT GENERAL HOSPITAL EMERGENCY DEPARTMENT
Practice Address - Street 2:640 SOUTH STATE ST.
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901
Practice Address - Country:US
Practice Address - Phone:302-674-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC0002745363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q15934Medicare UPIN
DE020814D18Medicare PIN