Basic Information
| Provider Information | |||||||||
| NPI: | 1639253537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 W BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395011058 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 13TH ST | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288653151 | ||||||||
| FaxNumber: | 2288674124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 07055 | MS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00012871 | 05 | MS | MEDICAID | 1639253537 | 05 | MO | MEDICAID |