Healthcare Provider Details

I. General information

NPI: 1285794529
Provider Name (Legal Business Name): GRACE L. SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 MARKET ST BLDG A
BOARDMAN OH
44512-3457
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-6085
  • Fax: 330-629-7620
Mailing address:
  • Phone: 330-629-6085
  • Fax: 330-629-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD045269L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number35-057808
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: