MEDICARE: ELYSE NICHOLE SMITH MD

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1447014998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELYSE NICHOLE SMITH MD

Provider Business Mailing Address
First Line	:	1967 OXFORD FARMS DR
Second Line	:
City	:	OXFORD
State	:	MS
Zip	:	38655-3040
Country	:	US
Telephone Number	:	601-540-7850
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 PRINCETON AVE SW
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35211-1323
Country	:	US
Telephone Number	:	205-599-4823
Fax Number	:

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

Provider Enumeration Date	:	02/06/2024
Last Update Date	:	01/12/2026

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