Healthcare Provider Details

I. General information

NPI: 1366412033
Provider Name (Legal Business Name): REBECCA L SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 FIRST BAXTER XING STE 101
FORT MILL SC
29708-8919
US

IV. Provider business mailing address

1700 FIRST BAXTER XING STE 101
FORT MILL SC
29708-8919
US

V. Phone/Fax

Practice location:
  • Phone: 803-802-3376
  • Fax:
Mailing address:
  • Phone: 803-802-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberNC9901324
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberNC9901324
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number15514
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number15514
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: