Provider Demographics
NPI:1093715096
Name:SMITH, PATRICK RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:RAYMOND
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 CARDWELL STREET
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR
Mailing Address - State:MO
Mailing Address - Zip Code:63077
Mailing Address - Country:US
Mailing Address - Phone:636-629-3300
Mailing Address - Fax:636-629-7377
Practice Address - Street 1:1001 CARDWELL ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1094
Practice Address - Country:US
Practice Address - Phone:636-629-3300
Practice Address - Fax:636-629-7377
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01135423OtherRAILROAD MEDICARE
MO208282608Medicaid
MO208282608Medicaid
129430011Medicare PIN
MO152810052Medicare PIN
MO0767820001Medicare NSC