Healthcare Provider Details

I. General information

NPI: 1023075983
Provider Name (Legal Business Name): JAMES LACEY SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 MARINA COVE DR
COLUMBUS GA
31904
US

IV. Provider business mailing address

1207 MARINA COVE DR
COLUMBUS GA
31904-2285
US

V. Phone/Fax

Practice location:
  • Phone: 901-412-1881
  • Fax:
Mailing address:
  • Phone: 901-412-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number19469
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number075543
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: