Provider Demographics
NPI:1083829139
Name:KELLY J SMITH MD PA
Entity Type:Organization
Organization Name:KELLY J SMITH MD PA
Other - Org Name:CHILDREN'S ASTHMA, SLEEP & PULMONARY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-615-3700
Mailing Address - Street 1:5282 MEDICAL DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4849
Mailing Address - Country:US
Mailing Address - Phone:210-615-3700
Mailing Address - Fax:210-615-3701
Practice Address - Street 1:5282 MEDICAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4849
Practice Address - Country:US
Practice Address - Phone:210-615-3700
Practice Address - Fax:210-615-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3394207RS0012X, 2080S0012X
2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191771801Medicaid
TX00Y631Medicare PIN