Provider Demographics
NPI:1568486850
Name:SMITH, MARK ROSS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROSS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4306
Mailing Address - Country:US
Mailing Address - Phone:417-837-4000
Mailing Address - Fax:417-875-4766
Practice Address - Street 1:2828 N NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4306
Practice Address - Country:US
Practice Address - Phone:417-837-4000
Practice Address - Fax:417-875-4766
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112770207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1568486850Medicaid
MO204683742Medicaid
P00364219OtherRR MEDICARE
MOMA1327009Medicare PIN
MO1568486850Medicaid
MO204683742Medicaid