Healthcare Provider Details

I. General information

NPI: 1790045094
Provider Name (Legal Business Name): BRYAN WESLEY SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 DEVINE ST
COLUMBIA SC
29208-3902
US

IV. Provider business mailing address

1409 DEVINE ST
COLUMBIA SC
29208-3902
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-2913
  • Fax: 803-777-0126
Mailing address:
  • Phone: 803-777-2913
  • Fax: 803-777-0126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number34586
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number39745
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: