Healthcare Provider Details

I. General information

NPI: 1902965965
Provider Name (Legal Business Name): CAROLYN SHANNON SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 N 15TH ST
MILWAUKEE WI
53233-2237
US

IV. Provider business mailing address

240 W INDIAN CREEK CT
MILWAUKEE WI
53217-2323
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-7184
  • Fax:
Mailing address:
  • Phone: 414-540-6593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number38125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: