Basic Information
| Provider Information | |||||||||
| NPI: | 1831142074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | CARLA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 SKYLINE BLVD | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791271 | ||||||||
| FaxNumber: | 2188798904 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 JAY COOKE RD | ||||||||
| Address2: | |||||||||
| City: | ESKO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557339727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183913937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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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 | 207Q00000X | 40811 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 708820500 | 05 | MN | MEDICAID |