Provider Demographics
NPI:1568642189
Name:SMITH, THOMAS BYRON (MED)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BYRON
Last Name:SMITH
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 918
Mailing Address - Street 2:1035 CHERAW ST.
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-0918
Mailing Address - Country:US
Mailing Address - Phone:843-454-0841
Mailing Address - Fax:843-454-0635
Practice Address - Street 1:1035 CHERAW ST.
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512
Practice Address - Country:US
Practice Address - Phone:843-454-0442
Practice Address - Fax:843-454-0212
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00050884101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
WARC00050884OtherDEPARTMENT OF HEALTH
3343Medicare PIN