Healthcare Provider Details

I. General information

NPI: 1598144917
Provider Name (Legal Business Name): BRIAN SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12277 DE PAUL DR STE 100
BRIDGETON MO
63044-2577
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-5142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.134016
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2021011406
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: