Healthcare Provider Details

I. General information

NPI: 1629298757
Provider Name (Legal Business Name): BRIAN SAMUEL SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

IV. Provider business mailing address

415 BROAD ST SUITE 410
KINGSPORT TN
37660-4263
US

V. Phone/Fax

Practice location:
  • Phone: 337-609-5109
  • Fax:
Mailing address:
  • Phone: 423-239-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101256622
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number48138
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: