Provider Demographics
NPI:1558576454
Name:SMITH, STACI CHARLENE (DO)
Entity Type:Individual
Prefix:MS
First Name:STACI
Middle Name:CHARLENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2828 1ST AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1236
Mailing Address - Country:US
Mailing Address - Phone:304-525-7111
Mailing Address - Fax:304-525-7112
Practice Address - Street 1:2828 1ST AVE STE 204
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1236
Practice Address - Country:US
Practice Address - Phone:304-525-7111
Practice Address - Fax:304-525-7112
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010025207RH0002X
WV2458207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1558576454 (THSPP)Medicaid
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WVWV3285B441Medicare PIN