Healthcare Provider Details

I. General information

NPI: 1891075867
Provider Name (Legal Business Name): GREGORY N. SMITH MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S 18TH ST SUTIE 204
AMELIA ISLAND FL
32034-1902
US

IV. Provider business mailing address

1250 S 18TH ST SUITE 204
AMELIA ISLAND FL
32034-1902
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-8787
  • Fax: 904-261-9353
Mailing address:
  • Phone: 904-261-8787
  • Fax: 904-261-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME66525
License Number StateFL

VIII. Authorized Official

Name: DR. GREGORY NEAL SMITH
Title or Position: OWNER
Credential: MD
Phone: 904-261-8787