Provider Demographics
NPI:1386985307
Name:ARNOLD GRAHAM SMITH, MD PA
Entity type:Organization
Organization Name:ARNOLD GRAHAM SMITH, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN/VP
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-391-6862
Mailing Address - Street 1:9191 R G SKINNER PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9655
Mailing Address - Country:US
Mailing Address - Phone:904-391-6862
Mailing Address - Fax:904-391-1005
Practice Address - Street 1:9191 R G SKINNER PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9655
Practice Address - Country:US
Practice Address - Phone:904-391-6862
Practice Address - Fax:904-391-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0039103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
15651OtherBCBS PROVIDER NUMBER
15651OtherBCBS PROVIDER NUMBER
D52683Medicare UPIN