Provider Demographics
NPI:1700923224
Name:SMITH, ANITA ROCHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:ROCHELLE
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 1:4801 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2015
Mailing Address - Country:US
Mailing Address - Phone:320-255-6350
Mailing Address - Fax:320-255-6426
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-255-6350
Practice Address - Fax:320-255-6426
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25830171000000X, 207R00000X
GA061659207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630000013Medicaid
AL011486OtherMEDICARE GROUP NUMBER
AL1063439065OtherSITE NPI GROUP PAYEE NUMBER