Healthcare Provider Details

I. General information

NPI: 1609335751
Provider Name (Legal Business Name): CHARLES L SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 SHERATON BLVD
MACON GA
31210-1359
US

IV. Provider business mailing address

275 SHERATON BLVD
MACON GA
31210-1359
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-5779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11839039-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number96776
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: