Healthcare Provider Details

I. General information

NPI: 1790105682
Provider Name (Legal Business Name): SHEREA MONICA SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 04/17/2025
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV PED ACADEMICS, STE 2D
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6300
  • Fax: 833-969-0131
Mailing address:
  • Phone: 314-454-6300
  • Fax: 833-969-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2017010075
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number2017010075
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: