Healthcare Provider Details

I. General information

NPI: 1336655745
Provider Name (Legal Business Name): LORI SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 PARK AVE STE 400
MEMPHIS TN
38119-5214
US

IV. Provider business mailing address

956 JOHN IVY RD
CARTHAGE MS
39051-7213
US

V. Phone/Fax

Practice location:
  • Phone: 901-767-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number23602
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23602
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number23602
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: