Provider Demographics
NPI:1023065414
Name:SMITH, MELISSA ANN (DC)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:10504 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1306
Mailing Address - Country:US
Mailing Address - Phone:314-822-4646
Mailing Address - Fax:314-822-8820
Practice Address - Street 1:10504 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1306
Practice Address - Country:US
Practice Address - Phone:314-822-4646
Practice Address - Fax:314-822-8820
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003011578111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO665395OtherUNITED HEALTH CARE
MO192225OtherBLUE CROSS BLUE SHEILD
MOV07416Medicare UPIN
MO665395OtherUNITED HEALTH CARE
MO00025916Medicare ID - Type Unspecified