Healthcare Provider Details

I. General information

NPI: 1700923224
Provider Name (Legal Business Name): ANITA ROCHELLE SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6350
  • Fax: 320-255-6426
Mailing address:
  • Phone: 320-255-6350
  • Fax: 320-255-6426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number25830
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25830
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number061659
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number061659
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: