Provider Demographics
NPI:1174584148
Name:SMITH, THOMAS DALE (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18019 NW AMBER CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-5918
Mailing Address - Country:US
Mailing Address - Phone:816-891-0922
Mailing Address - Fax:816-777-1200
Practice Address - Street 1:8929 PARALLEL PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-1689
Practice Address - Country:US
Practice Address - Phone:913-596-4685
Practice Address - Fax:913-596-4466
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160553207LP2900X, 208VP0014X
KS04-23206207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSE50649Medicare UPIN
KS2201803Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #