1700990827 NPI number — DR. LEAH LANE SHUTT SMITH MD

Table of content: DR. LEAH LANE SHUTT SMITH MD (NPI 1700990827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700990827 NPI number — DR. LEAH LANE SHUTT SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
LEAH LANE
Provider Middle Name:
SHUTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHUTT
Provider Other First Name:
LEAH
Provider Other Middle Name:
LANE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700990827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 CLEMSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29229-4341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-788-6146
Provider Business Mailing Address Fax Number:
803-462-0312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4568 SUNSET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29072-9250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-520-5144
Provider Business Practice Location Address Fax Number:
803-462-0312
Provider Enumeration Date:
08/18/2006

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: 208000000X , with the licence number:  200600241 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 30653 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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