Provider Demographics
NPI:1003874892
Name:SMITH, CHARLIE D III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:D
Last Name:SMITH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:OLANTA
Mailing Address - State:SC
Mailing Address - Zip Code:29114-0266
Mailing Address - Country:US
Mailing Address - Phone:843-687-0153
Mailing Address - Fax:843-673-9457
Practice Address - Street 1:2322 BURNT BRANCH RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-7910
Practice Address - Country:US
Practice Address - Phone:843-687-0153
Practice Address - Fax:843-673-9457
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13042208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1679530968OtherGROUP NPI
SC130423Medicaid
SC7937OtherMEDICARE GROUP NUMBER
SC7937OtherMEDICARE GROUP NUMBER
SC130423Medicaid