Healthcare Provider Details

I. General information

NPI: 1558576454
Provider Name (Legal Business Name): STACI CHARLENE SMITH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1562
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax: 740-446-5573
Mailing address:
  • Phone: 855-446-5937
  • Fax: 740-446-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2458
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number34.010025
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2458
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number04204
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number34.010025
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: