Healthcare Provider Details

I. General information

NPI: 1669922969
Provider Name (Legal Business Name): JUSTIN TAYLOR SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 MERCANTILE PL STE 101
FORT MILL SC
29715-2005
US

IV. Provider business mailing address

441 MERCANTILE PL STE 101
FORT MILL SC
29715-2005
US

V. Phone/Fax

Practice location:
  • Phone: 803-220-4207
  • Fax:
Mailing address:
  • Phone: 803-220-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2022-01292
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number85638
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: