Healthcare Provider Details

I. General information

NPI: 1558305490
Provider Name (Legal Business Name): ELLEN BLAIR SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W 38TH ST SUITE 200
AUSTIN TX
78705-1165
US

IV. Provider business mailing address

PO BOX 911230
DALLAS TX
75391-1230
US

V. Phone/Fax

Practice location:
  • Phone: 512-419-9733
  • Fax: 512-451-3709
Mailing address:
  • Phone: 972-997-8000
  • Fax: 972-234-0813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberF0313
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: