Healthcare Provider Details

I. General information

NPI: 1518033158
Provider Name (Legal Business Name): TIA SMITH NEELY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIA SMITH SANDERLIN MD

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 HOMER RD STE A
COMMERCE GA
30529-8802
US

IV. Provider business mailing address

PO BOX 117264
ATLANTA GA
30368-7264
US

V. Phone/Fax

Practice location:
  • Phone: 706-335-9060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number051379
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: