Basic Information
| Provider Information | |||||||||
| NPI: | 1669403093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH MAXEY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LEA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2585 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257031642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 2585 3RD AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047815138 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 22344 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3810005791 | 05 | WV | MEDICAID | 2667038 | 05 | OH | MEDICAID |