Basic Information
| Provider Information | |||||||||
| NPI: | 1982698387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 724 STONE AVE | ||||||||
| Address2: | |||||||||
| City: | TALLADEGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351602219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563621410 | ||||||||
| FaxNumber: | 2563620186 | ||||||||
| Practice Location | |||||||||
| Address1: | 724 STONE AVE | ||||||||
| Address2: | |||||||||
| City: | TALLADEGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351602219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563621410 | ||||||||
| FaxNumber: | 2563620186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/24/2006 | ||||||||
| NPIReactivationDate: | 04/05/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9293 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | AS8745474 | 01 | AL | DEA | OTHER | 9293 | 01 | AL | STATE MEDICAL LICENSE | OTHER | 529904160 | 05 | AL | MEDICAID |