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NPI Code Detail

MEDICARE: MR. EDMUND EARL SMITH PHYSICIAN ASSISTANT

MEDICARE: MR. EDMUND EARL SMITH PHYSICIAN ASSISTANT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant11049GA

General Provider Information

NPI Number : 1255952107
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. EDMUND EARL SMITH PHYSICIAN ASSISTANT
Provider Business Mailing Address
First Line : 580 HOLDERNESS ST SW
Second Line :
City : ATLANTA
State : GA
Zip : 30310-1747
Country : US
Telephone Number : 404-788-9091
Fax Number :
Provider Business Practice Location Address
First Line : 13081 HIGHWAY 9 N
Second Line :
City : ALPHARETTA
State : GA
Zip : 30004-5150
Country : US
Telephone Number : 770-521-6690
Fax Number : 770-521-6609
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2020
Last Update Date : 07/23/2024

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