1528051299 NPI number — LISA A MCKINNEY SMITH DO

Table of content: LISA A MCKINNEY SMITH DO (NPI 1528051299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528051299 NPI number — LISA A MCKINNEY SMITH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKINNEY SMITH
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528051299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37662-0009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-857-2093
Provider Business Mailing Address Fax Number:
423-390-3340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W STONE DR STE 1J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-378-7654
Provider Business Practice Location Address Fax Number:
423-578-8025
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  DO1464 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 0102201581 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005651B56 . This is a "TRAILBLAZERS MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3300707 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00149425 . This is a "PALMETTO RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00149425 . This is a "PALMETTO RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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