Healthcare Provider Details

I. General information

NPI: 1457565913
Provider Name (Legal Business Name): GREGORY WAYNE SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PARK CENTRAL DR SUITE 200
COLUMBIA SC
29203-6469
US

IV. Provider business mailing address

121 PARK CENTRAL DRIVE SUITE 200
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-252-9907
  • Fax: 803-252-9906
Mailing address:
  • Phone: 803-252-9907
  • Fax: 803-252-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number30652
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: