Healthcare Provider Details

I. General information

NPI: 1770979221
Provider Name (Legal Business Name): BLAKE GAITHER SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2015
Last Update Date: 02/01/2024
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 6TH AVE S FL 4
BIRMINGHAM AL
35233-2110
US

IV. Provider business mailing address

625 19TH STREET SOUTH
BIRMINGHAM AL
35249
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-7114
  • Fax:
Mailing address:
  • Phone: 731-446-1954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number35621
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD.35621
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: