Healthcare Provider Details

I. General information

NPI: 1619933744
Provider Name (Legal Business Name): BOBBY SMITH II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 WEST BEACON STREET
PHILADELPHIA MS
39350
US

IV. Provider business mailing address

921 WEST BEACON STREET
PHILADELPHIA MS
39350
US

V. Phone/Fax

Practice location:
  • Phone: 601-656-6116
  • Fax: 601-656-5445
Mailing address:
  • Phone: 601-656-6116
  • Fax: 601-656-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16026
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: