Provider Demographics
NPI:1932395084
Name:TERRY A. SMITH M.C.P.C.
Entity type:Organization
Organization Name:TERRY A. SMITH M.C.P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:406-822-4100
Mailing Address - Street 1:310 SPRUCE ST
Mailing Address - Street 2:PO BOX 340
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872-9680
Mailing Address - Country:US
Mailing Address - Phone:406-822-4100
Mailing Address - Fax:
Practice Address - Street 1:310 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872-9680
Practice Address - Country:US
Practice Address - Phone:406-822-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-22
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7350261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT97711OtherBLUE CROSS BLUE SHIELD
MT0066521Medicaid
MT97711OtherBLUE CROSS BLUE SHIELD