Basic Information
Provider Information | |||||||||
NPI: | 1639282692 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUSSELL | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1701 WESTCHESTER DR | ||||||||
Address2: | STE 850 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272627008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022400 | ||||||||
FaxNumber: | 3368022534 | ||||||||
Practice Location | |||||||||
Address1: | 1814 WESTCHESTER DR | ||||||||
Address2: | STE 301 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272627299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022025 | ||||||||
FaxNumber: | 3368022026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2006 | ||||||||
LastUpdateDate: | 02/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2006-00920 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 191794 | 01 | NC | MEDCOST | OTHER | 5904509 | 05 | NC |   | MEDICAID | 7118189 | 01 | NC | AETNA | OTHER | 808266 | 01 | NC | PARTNERS MEDICARE CHOICE | OTHER | 143EW | 01 | NC | BXBS | OTHER | 1639282692 | 05 | NC |   | MEDICAID | 232009 | 01 | NC | MEDICARE PTAN, GROUP | OTHER |