Healthcare Provider Details

I. General information

NPI: 1083077952
Provider Name (Legal Business Name): ANNA JO BODURTHA SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD FL 3
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

3000 CIVIC CENTER 10TH FLOOR, SOUTH TOWER
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3318
  • Fax: 215-349-5680
Mailing address:
  • Phone: 800-789-7366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD470800
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD470800
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: