1649694860 NPI number — MR. BRIDGES WADE SMITH III MS, LSPE

Table of content: MR. BRIDGES WADE SMITH III MS, LSPE (NPI 1649694860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649694860 NPI number — MR. BRIDGES WADE SMITH III MS, LSPE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
BRIDGES
Provider Middle Name:
WADE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
MS, LSPE
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:
1649694860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1241 VOLUNTEER PKWY
Provider Second Line Business Mailing Address:
SUITE 436
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-4659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-990-2315
Provider Business Mailing Address Fax Number:
423-990-2316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 VOLUNTEER PKWY
Provider Second Line Business Practice Location Address:
SUITE 436
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-4659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-990-2315
Provider Business Practice Location Address Fax Number:
423-990-2316
Provider Enumeration Date:
02/07/2014

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: 103TH0100X , with the licence number:  11716 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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