MEDICARE: LORI SMITH

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
1	207QA0505X	Adult Medicine Physician	23602	TN
2	208D00000X	General Practice Physician	23602	TN
3	208VP0000X	Pain Medicine Physician	23602	TN

General Provider Information

NPI Number	:	1336655745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI SMITH

Provider Business Mailing Address
First Line	:	956 JOHN IVY RD
Second Line	:
City	:	CARTHAGE
State	:	MS
Zip	:	39051-7213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6005 PARK AVE STE 400
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-5214
Country	:	US
Telephone Number	:	901-767-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2017
Last Update Date	:	12/20/2017

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Directions to “ LORI SMITH ” Practice Location

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