Provider Demographics
NPI:1215029590
Name:SMITH, SAMUEL A (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:SMITH
Suffix:
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 1:5301 VIRGINIA WAY
Mailing Address - Street 2:STE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7541
Mailing Address - Country:US
Mailing Address - Phone:615-221-4474
Mailing Address - Fax:615-234-3774
Practice Address - Street 1:5301 VIRGINIA WAY
Practice Address - Street 2:STE 300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7541
Practice Address - Country:US
Practice Address - Phone:615-221-4474
Practice Address - Fax:615-234-3774
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11267207ZP0102X
KY17355207ZP0102X
IN01025634207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3041620Medicaid
TN000000004401OtherTLC TENNCARE
TN119453OtherUNISON TENNCARE
TN3045394OtherBLUE CROSS
KY64745235Medicaid
TN3045394OtherBLUE CROSS
TN3041621Medicare ID - Type Unspecified
KY64745235Medicaid