Provider Demographics
NPI:1427056555
Name:SMITH, RANDALL N (MD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:N
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 1:9140 ACADEMY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2853
Mailing Address - Country:US
Mailing Address - Phone:215-333-9999
Mailing Address - Fax:215-333-9815
Practice Address - Street 1:9140 ACADEMY RD
Practice Address - Street 2:SUITE A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2853
Practice Address - Country:US
Practice Address - Phone:215-333-9999
Practice Address - Fax:215-333-9815
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015723E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000779617000Medicaid
PA000779617000Medicaid
PA104884Medicare ID - Type Unspecified