Basic Information
| Provider Information | |||||||||
| NPI: | 1629298757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 BROAD ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232399737 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 415 BROAD ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234392737 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 48138 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0101256622 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.