MEDICARE: MR. MARK WARREN SMITH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34000746A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000345326	OTHER	IN	ANTHEM ID NUMBER

General Provider Information

NPI Number	:	1336296458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK WARREN SMITH LCSW

Provider Business Mailing Address
First Line	:	819 E 64TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-1671
Country	:	US
Telephone Number	:	317-251-5504
Fax Number	:	317-251-1691

Provider Business Practice Location Address
First Line	:	819 E 64TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-1671
Country	:	US
Telephone Number	:	317-251-5504
Fax Number	:	317-251-1691

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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