Healthcare Provider Details

I. General information

NPI: 1780901900
Provider Name (Legal Business Name): NELSON SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

IV. Provider business mailing address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5590
  • Fax: 304-388-8238
Mailing address:
  • Phone: 304-388-5590
  • Fax: 304-388-8238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2564
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2564
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: