Healthcare Provider Details

I. General information

NPI: 1558424796
Provider Name (Legal Business Name): EDWARD J SMITH D.C. P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 CHARLIE SMITH SR. HWY.
ST. MARYS GA
31558
US

IV. Provider business mailing address

PO BOX 5035
SAINT MARYS GA
31558-5035
US

V. Phone/Fax

Practice location:
  • Phone: 912-882-7880
  • Fax: 912-882-7311
Mailing address:
  • Phone: 912-882-7880
  • Fax: 912-882-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2860
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: