Healthcare Provider Details

I. General information

NPI: 1235235680
Provider Name (Legal Business Name): DR. ROOSEVELT J SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4518-A WEST MARKET ST
GREENSBORO NC
27407
US

IV. Provider business mailing address

4518-A WEST MARKET ST
GREENSBORO NC
27407
US

V. Phone/Fax

Practice location:
  • Phone: 336-235-4022
  • Fax: 336-235-4023
Mailing address:
  • Phone: 336-235-4022
  • Fax: 336-235-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2930
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: