MEDICARE: MS. STACI CHARLENE SMITH DO

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	207RN0300X	Nephrology Physician	34.010025	OH
2	207R00000X	Internal Medicine Physician	2458	WV
3	207RN0300X	Nephrology Physician	2458	WV
4	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician	34.010025	OH
5	207RN0300X	Nephrology Physician	04204	KY

General Provider Information

NPI Number	:	1558576454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACI CHARLENE SMITH DO

Provider Business Mailing Address
First Line	:	90 JACKSON PIKE
Second Line	:
City	:	GALLIPOLIS
State	:	OH
Zip	:	45631-1562
Country	:	US
Telephone Number	:	855-446-5937
Fax Number	:	740-446-5573

Provider Business Practice Location Address
First Line	:	100 JACKSON PIKE
Second Line	:
City	:	GALLIPOLIS
State	:	OH
Zip	:	45631-1560
Country	:	US
Telephone Number	:	855-446-5937
Fax Number	:	740-446-5573

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

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	03/12/2026

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