Healthcare Provider Details

I. General information

NPI: 1063709418
Provider Name (Legal Business Name): GEORGE RAYFORD SMITH II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 MARION DR.
MCCOMB MS
39648-4040
US

IV. Provider business mailing address

3640 POPLAR SPRINGS DR
MERIDIAN MS
39305-3741
US

V. Phone/Fax

Practice location:
  • Phone: 601-249-5500
  • Fax:
Mailing address:
  • Phone: 504-578-7744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR881364
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: