Provider Demographics
NPI:1043234024
Name:MITCHELL-SMITH, ALICE M (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:M
Last Name:MITCHELL-SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:M
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:RM DG412
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-963-1400
Practice Address - Fax:317-962-4950
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400555207P00000X, 2085U0001X
IN01070795A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891372HMedicaid
SCN0055DMedicaid
NC1372HOtherNCBCBS
IN201061700Medicaid
INP01401790Medicare PIN
NC891372HMedicaid
INM400075689Medicare PIN
2027759AMedicare PIN
IN201061700Medicaid
INM400075688Medicare PIN
SCN0055DMedicaid
INP01320216Medicare PIN