Provider Demographics
NPI:1306868575
Name:SMITH, MERVYN P JR (MD)
Entity type:Individual
Prefix:DR
First Name:MERVYN
Middle Name:P
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 24146
Mailing Address - Street 2:UNIVERSITY PHYSICIANS PLLC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4146
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/DIVISION OF CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2009-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS07057207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00462325OtherRAILROAD MEDICARE PTAN
MS01279231Medicaid
LA1627861Medicaid
MS512I060001Medicare PIN
MSB30168Medicare UPIN
LA1627861Medicaid