Healthcare Provider Details

I. General information

NPI: 1871621474
Provider Name (Legal Business Name): SUSAN J SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN SMITH STEFANIUK MD

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 CINEMA DRIVE
ELLIJAY GA
30540-2592
US

IV. Provider business mailing address

165 BLUE RIDGE OVERLOOK
BLUE RIDGE GA
30513-4431
US

V. Phone/Fax

Practice location:
  • Phone: 706-635-6898
  • Fax: 706-635-6885
Mailing address:
  • Phone: 706-946-5607
  • Fax: 706-374-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number030547
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: