Basic Information
| Provider Information | |||||||||
| NPI: | 1134173008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 403 HILLCREST DR STE C | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296401207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648551644 | ||||||||
| FaxNumber: | 8648556101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 12485 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1407154 | 01 | SC | CIGNA ID | OTHER | 576007863142 | 01 | SC | BCBS OF SC ID | OTHER | 4417333 | 01 | SC | AETNA ID | OTHER | 576007863132 | 01 | SC | BLUECHOICE HEALTHPLAN ID | OTHER | 124859 | 05 | SC | MEDICAID | P00305815 | 01 | SC | RR MEDICARE | OTHER |