Healthcare Provider Details

I. General information

NPI: 1710482534
Provider Name (Legal Business Name): COLLIN CHRISTOPHER SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

IV. Provider business mailing address

PO BOX 1547
CHARLESTON WV
25326-1547
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7170
  • Fax: 304-388-6597
Mailing address:
  • Phone: 304-388-6004
  • Fax: 304-388-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number0102207243
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number3717
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102207243
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3717
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: