Provider Demographics
NPI:1942490420
Name:SMITH, JILLIAN KENNEDY (MD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:KENNEDY
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CAMPUS DR UNIT 121
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7172
Mailing Address - Country:US
Mailing Address - Phone:207-396-7788
Mailing Address - Fax:
Practice Address - Street 1:100 CAMPUS DR UNIT 121
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7172
Practice Address - Country:US
Practice Address - Phone:207-396-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD452016208600000X, 2086X0206X
MEMD247062086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031635120002Medicaid
PA1031635120001Medicaid