Healthcare Provider Details

I. General information

NPI: 1811930266
Provider Name (Legal Business Name): GARY SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 N 9TH AVE SHMG HOSPITALIST
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

PO BOX 2699 ATTN: SHMG/HPE
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7619
  • Fax: 850-416-7753
Mailing address:
  • Phone: 850-416-7619
  • Fax: 850-416-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD01697
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS13799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: