Basic Information
| Provider Information | |||||||||
| NPI: | 1285839670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 W ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278345704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524136202 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1850 W ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278345704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524136202 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NC2010-01082 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2010-01082 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5916698 | 05 | NC | MEDICAID | 161CP | 01 | NC | BCBSNC | OTHER |