1669543807 NPI number — PAUL GRAYSON SMITH III D.O.

Table of content: PAUL GRAYSON SMITH III D.O. (NPI 1669543807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669543807 NPI number — PAUL GRAYSON SMITH III D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
PAUL
Provider Middle Name:
GRAYSON
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1669543807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 HUNT CLIFF DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37311-1642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-903-8339
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 N OCOEE ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37311-3953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-472-6548
Provider Business Practice Location Address Fax Number:
423-472-8318
Provider Enumeration Date:
11/10/2006

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: 207Q00000X , with the licence number:  DO1806 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: OS9860 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: FP62706 . This is a "WORKERS COMP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3719099 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: X86491 . This is a "HEALTH SPRING" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 11715949 . This is a "CAQH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "JOHN DEERE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4155514 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: DO1806 . This is a "STATE LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 6635438 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".