MEDICARE: DR. LEROY CARTER 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	207QA0505X	Adult Medicine Physician	26371	NC
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	26371	NC
3	208600000X	Surgery Physician	41584	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700830601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEROY CARTER SMITH M.D.

Provider Business Mailing Address
First Line	:	2755 SILVER CREEK RD
Second Line	:	SUITE 111
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7904
Country	:	US
Telephone Number	:	928-704-7163
Fax Number	:	928-704-7140

Provider Business Practice Location Address
First Line	:	2755 SILVER CREEK RD
Second Line	:	SUITE 111
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7904
Country	:	US
Telephone Number	:	928-704-7163
Fax Number	:	928-704-7140

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

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	02/21/2012

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