Provider Demographics
NPI:1336655745
Name:SMITH, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 JOHN IVY RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-7213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE STE 400
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5214
Practice Address - Country:US
Practice Address - Phone:901-767-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23602207QA0505X, 208D00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice