Basic Information
| Provider Information | |||||||||
| NPI: | 1922095561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | GALT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E BROOKLYN ST | ||||||||
| Address2: | P.O. BOX 916 | ||||||||
| City: | LINDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370963515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315892104 | ||||||||
| FaxNumber: | 9315892513 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 E BROOKLYN ST | ||||||||
| Address2: | |||||||||
| City: | LINDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370963515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315892104 | ||||||||
| FaxNumber: | 9315892513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 05/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9601143 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 021861 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3064922 | 05 | TN | MEDICAID | 8976820 | 05 | NC | MEDICAID | N01143 | 05 | SC | MEDICAID |