Healthcare Provider Details

I. General information

NPI: 1275986903
Provider Name (Legal Business Name): MR. GREG R SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 WINDSOR ST SW SUITE 203
ATLANTA GA
30312-2530
US

IV. Provider business mailing address

477 WINDSOR ST SW SUITE 203
ATLANTA GA
30312-2530
US

V. Phone/Fax

Practice location:
  • Phone: 404-594-1447
  • Fax:
Mailing address:
  • Phone: 404-594-1447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2470A2800X
TaxonomyAssistant Health Information Record Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: