Healthcare Provider Details

I. General information

NPI: 1043365984
Provider Name (Legal Business Name): ANGELA RENEE SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE MMC 293
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

331 COTTAGE AVE W
SAINT PAUL MN
55117-4348
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-7634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number46413
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: