Basic Information
Provider Information | |||||||||
NPI: | 1043384183 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SMITH & PURVIS FAMILY PRACTICE CLINIC, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STATESBORO FAMILY PRACTICE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 412 NORTHSIDE DR E | ||||||||
Address2: | SUITE 200 | ||||||||
City: | STATESBORO | ||||||||
State: | GA | ||||||||
PostalCode: | 304584802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9127649684 | ||||||||
FaxNumber: | 9124898676 | ||||||||
Practice Location | |||||||||
Address1: | 412 NORTHSIDE DR E | ||||||||
Address2: | SUITE 200 | ||||||||
City: | STATESBORO | ||||||||
State: | GA | ||||||||
PostalCode: | 304584802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9127649684 | ||||||||
FaxNumber: | 9124898676 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAIGNEAULT | ||||||||
AuthorizedOfficialFirstName: | TERI | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL CODER | ||||||||
AuthorizedOfficialTelephone: | 9127641039 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 029847 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 048703 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 18745 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.