Basic Information
| Provider Information | |||||||||
| NPI: | 1376586958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 204 PROFESSIONAL CT SE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307017020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066255900 | ||||||||
| FaxNumber: | 7066256519 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 PROFESSIONAL CT SE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307017020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066255900 | ||||||||
| FaxNumber: | 7066256519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 045059 | GA | Y | Other Service Providers | Specialist |
No ID Information.