Provider Demographics
NPI:1649298076
Name:SMITH, CAROLYN ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:314-851-4445
Practice Address - Street 1:13303 TESSON FERRY RD STE 150
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-842-5239
Practice Address - Fax:314-842-3835
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003010764208000000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208819607Medicaid
ILENROLLEDMedicaid
ILENROLLEDMedicaid
MO319010381Medicaid