Provider Demographics
NPI:1326061623
Name:SMITH, BENJAMIN J (PAC)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6618
Mailing Address - Country:US
Mailing Address - Phone:229-225-1900
Mailing Address - Fax:229-225-3455
Practice Address - Street 1:119 W HILL ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6618
Practice Address - Country:US
Practice Address - Phone:229-225-1900
Practice Address - Fax:229-225-3455
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA905363A00000X
GA3410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS92386Medicare UPIN
GA97BBFHHMedicare PIN