Provider Demographics
NPI:1578569687
Name:SMITH, CHARLES MICHAEL JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6025 WALNUT GROVE RD
Mailing Address - Street 2:STE 508
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2125
Mailing Address - Country:US
Mailing Address - Phone:901-767-5864
Mailing Address - Fax:901-767-6591
Practice Address - Street 1:6025 WALNUT GROVE RD
Practice Address - Street 2:STE 508
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2125
Practice Address - Country:US
Practice Address - Phone:901-767-5864
Practice Address - Fax:901-767-6591
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD26141207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I295085Medicare PIN
MS302I295205Medicare PIN