Provider Demographics
NPI:1629249032
Name:LOVELL SMITH
Entity Type:Organization
Organization Name:LOVELL SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOVELL
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:866-224-5612
Mailing Address - Street 1:6027 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2145
Mailing Address - Country:US
Mailing Address - Phone:866-224-5612
Mailing Address - Fax:901-853-4530
Practice Address - Street 1:6027 WALNUT GROVE RD
Practice Address - Street 2:SUITE 118
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2145
Practice Address - Country:US
Practice Address - Phone:866-224-5612
Practice Address - Fax:901-853-4530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39730208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicaid