Provider Demographics
NPI:1487688834
Name:SMITH, EMMANUEL ADEMOLA (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ADEMOLA
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 1:3998 RED LION RD STE 214
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1440
Mailing Address - Country:US
Mailing Address - Phone:215-612-4700
Mailing Address - Fax:
Practice Address - Street 1:261 MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:MERION STATION
Practice Address - State:PA
Practice Address - Zip Code:19066-1231
Practice Address - Country:US
Practice Address - Phone:610-771-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066013L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1147631OtherAETNA
PA30027672OtherKEYSTONE MERCY
PA36420MD066013LOtherHEALTH PARTNERS
PA2678918000OtherKEYSTONE HP/PC
PASM1821064OtherHIGHMARK BLUESHIELD
PAG85596Medicare UPIN