Healthcare Provider Details

I. General information

NPI: 1407844624
Provider Name (Legal Business Name): ELIZABETH ANNE SMITH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N 4TH AVE SW
ROME GA
30165-2812
US

IV. Provider business mailing address

11347 BIG BEND RD
RIVERVIEW FL
33579-7183
US

V. Phone/Fax

Practice location:
  • Phone: 706-292-3045
  • Fax: 706-292-3044
Mailing address:
  • Phone: 813-418-7282
  • Fax: 813-677-7141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME61157
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: