Healthcare Provider Details

I. General information

NPI: 1043474372
Provider Name (Legal Business Name): JILLIAN SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST DEPT OF EMERGENCY MEDICINE
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

1000 ASYLUM AVE SUITE 2109A
HARTFORD CT
06105-1770
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4001
  • Fax:
Mailing address:
  • Phone: 860-714-6581
  • Fax: 860-714-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21196
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number049542
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: