Provider Demographics
NPI:1275587982
Name:SMITH, THEODORE RAVENEL (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RAVENEL
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1690 SKYLYN DR STE 210
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1075
Practice Address - Country:US
Practice Address - Phone:864-253-8170
Practice Address - Fax:864-585-7787
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCE4946067OtherMEDICARE PIN
GAP00386787OtherMEDICARE RAILROAD PTAN#
SC074939Medicaid
SCSCE4946084OtherMEDICARE PIN
SCSCE494J577OtherMEDICARE PIN
SC074939Medicaid