Healthcare Provider Details

I. General information

NPI: 1326239575
Provider Name (Legal Business Name): MARY NANNA SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY SUITE 304
ANNAPOLIS MD
21401-3742
US

IV. Provider business mailing address

3299 WOODBURN RD SUITE 350
ANNANDALE VA
22003-1275
US

V. Phone/Fax

Practice location:
  • Phone: 410-573-9530
  • Fax: 410-573-9569
Mailing address:
  • Phone: 703-260-1179
  • Fax: 703-260-1179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0070737
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License NumberD0070737
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101252905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: