Healthcare Provider Details

I. General information

NPI: 1316444565
Provider Name (Legal Business Name): TAYLOR RYAN SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 JOHN MADDOX DR NW
ROME GA
30165-1419
US

IV. Provider business mailing address

103 JOHN MADDOX DR NW
ROME GA
30165-1419
US

V. Phone/Fax

Practice location:
  • Phone: 706-235-7711
  • Fax: 706-235-9944
Mailing address:
  • Phone: 706-235-7711
  • Fax: 706-235-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number320110
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number92896
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: