MEDICARE: HOLLY GWEN SMITH M.D.

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	208000000X	Pediatrics Physician	2005-00116	NC

General Provider Information

NPI Number	:	1689749418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY GWEN SMITH M.D.

Provider Business Mailing Address
First Line	:	6115 PARK SOUTH DR
Second Line	:	SUITE 105
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-3269
Country	:	US
Telephone Number	:	704-944-8388
Fax Number	:	704-944-8389

Provider Business Practice Location Address
First Line	:	6488 WEDDINGTON-MONROE RD
Second Line	:
City	:	WESLEY CHAPEL
State	:	NC
Zip	:	28104-6277
Country	:	US
Telephone Number	:	704-384-8460
Fax Number	:	704-384-1018

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	10/25/2020

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