Healthcare Provider Details

I. General information

NPI: 1093376568
Provider Name (Legal Business Name): ELIZABETH ANNE SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
MAPLEWOOD MN
55109-1126
US

IV. Provider business mailing address

2829 UNIVERSITY AVE SE STE 730
MINNEAPOLIS MN
55414-3279
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-7348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036165357
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number87846-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number83297
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: