Provider Demographics
NPI:1902906225
Name:SMITH, GREGORY M (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
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 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8757
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8757
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37917207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE41091744413Medicaid
MN11-00293OtherMEDICA
TX1476632Medicaid
MN655317600Medicaid
MNHP22459OtherHEALTHPARTNERS
MN1009671OtherPREFERREDONE
ND10155Medicaid
MN8D657SMOtherBCBS
MN124499OtherUCAREMN
MNE70175Medicare UPIN
MN229000237Medicare ID - Type UnspecifiedMEDICARE
NE41091744413Medicaid
TX1476632Medicaid