Provider Demographics
NPI:1437199312
Name:SMITH, MICHAEL SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1765 OLD WEST BROAD ST BLDG 2-200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2887
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:706-546-8792
Practice Address - Street 1:3440 HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-9112
Practice Address - Country:US
Practice Address - Phone:770-554-5009
Practice Address - Fax:706-549-1663
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53174207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
11590116OtherCAQH NUMBER
GA877121152AMedicaid