Healthcare Provider Details

I. General information

NPI: 1386640316
Provider Name (Legal Business Name): GREGORY H SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 OLD DES PERES RD
SAINT LOUIS MO
63131-1865
US

IV. Provider business mailing address

339 CONSORT DR
BALLWIN MO
63011-4439
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-8644
  • Fax: 314-821-4858
Mailing address:
  • Phone: 636-386-9224
  • Fax: 636-386-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberR1E02
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: