Provider Demographics
NPI:1528135829
Name:SMITH, RICHARD DALE (PA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:205 BURNS CROSSING ROAD
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-3408
Mailing Address - Country:US
Mailing Address - Phone:410-305-0348
Mailing Address - Fax:
Practice Address - Street 1:5755 CEDAR LANE SUITE 134
Practice Address - Street 2:HOWARD COUNTY GENERAL HOSPITAL EMERGENCY ROOM
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044
Practice Address - Country:US
Practice Address - Phone:410-884-4746
Practice Address - Fax:410-884-4749
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD988LF567Medicare PIN