Healthcare Provider Details

I. General information

NPI: 1255444386
Provider Name (Legal Business Name): STEPHEN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 S MAIN ST
SOCIETY HILL SC
29593-8972
US

IV. Provider business mailing address

PO BOX 1090
HARTSVILLE SC
29551-1090
US

V. Phone/Fax

Practice location:
  • Phone: 843-378-4501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16284
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: