Healthcare Provider Details

I. General information

NPI: 1427233048
Provider Name (Legal Business Name): RAYMOND GLENN SMITH IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PINCKNEY BLVD
BEAUFORT SC
29902-6122
US

IV. Provider business mailing address

1 PINCKNEY BLVD
BEAUFORT SC
29902-6122
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-3633
  • Fax:
Mailing address:
  • Phone: 843-228-3633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: