=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508868464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY N SMITH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2005
-----------------------------------------------------
Last Update Date | 11/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 S 18TH ST SUITE 204
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-8787
-----------------------------------------------------
Fax | 904-261-9353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 SAN MARCO BLVD SUITE 200
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-346-3465
-----------------------------------------------------
Fax | 904-261-9353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | ME66525
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------