Basic Information
| Provider Information | |||||||||
| NPI: | 1740247972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100523 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 W HAMLET AVE | ||||||||
| Address2: | RADIOLOGY DEPT | ||||||||
| City: | HAMLET | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283454522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 38691 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 944274 | 01 | NC | DESERET MUTUAL | OTHER | G49673 | 05 | SC | MEDICAID | 611473300 | 01 | NC | US DEPT OF LABOR | OTHER | 1230K | 01 | NC | BCBS OF NC | OTHER | 5902965 | 05 | NC | MEDICAID | 203824712 | 01 | NC | STANDARD TAX ID | OTHER |