Healthcare Provider Details

I. General information

NPI: 1013771468
Provider Name (Legal Business Name): KIARA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF GENERAL PEDIATRICS
PHILDELPHIA PA
19104
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD DIVISION OF GENERAL PEDIATRICS
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1220
  • Fax:
Mailing address:
  • Phone: 215-590-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT237641
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: