Healthcare Provider Details

I. General information

NPI: 1033111810
Provider Name (Legal Business Name): ANDREW GERALD SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 413021 DEPARTMENT OF PEDIATRICS - INPATIENT MEDICINE
SALT LAKE CITY UT
84141-3021
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-3673
  • Fax: 801-662-3664
Mailing address:
  • Phone: 801-213-3900
  • Fax: 801-585-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberTL3586
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5412561-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number5412561-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: