Healthcare Provider Details

I. General information

NPI: 1093715096
Provider Name (Legal Business Name): PATRICK RAYMOND SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CARDWELL ST
SAINT CLAIR MO
63077-1094
US

IV. Provider business mailing address

1001 CARDWELL STREET
ST. CLAIR MO
63077
US

V. Phone/Fax

Practice location:
  • Phone: 636-629-3300
  • Fax: 636-629-7377
Mailing address:
  • Phone: 636-629-3300
  • Fax: 636-629-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number104058
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: