Provider Demographics
NPI:1851373153
Name:SMITH, SALLY M
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:SMITH
Other - Last Name:MILLIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2855 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6701
Mailing Address - Country:US
Mailing Address - Phone:727-323-2727
Mailing Address - Fax:727-327-8101
Practice Address - Street 1:2855 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6701
Practice Address - Country:US
Practice Address - Phone:727-323-2727
Practice Address - Fax:727-327-8101
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057818208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063707600Medicaid
FL11519OtherBCBS
D18669Medicare UPIN