Basic Information
| Provider Information | |||||||||
| NPI: | 1760485312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 W MAIN ST | ||||||||
| Address2: | P O BOX 158 | ||||||||
| City: | COLE CAMP | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653250158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606680851 | ||||||||
| FaxNumber: | 6606683041 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 S 10TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653012540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608867800 | ||||||||
| FaxNumber: | 6608863346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R4P88 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 26387027 | 01 | MO | BLUE CROSS BLUE SHIELD PIN | OTHER | 203369715 | 05 | MO | MEDICAID |