Provider Demographics
NPI:1639182553
Name:SMITH, STEPHEN DEREK (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DEREK
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:678-854-9235
Practice Address - Street 1:80 NEWNAN STATION DRIVE, SUITE A
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-251-2060
Practice Address - Fax:678-854-9235
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN076030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52267829-002OtherBLUE CROSS BLUE SHIELD
GA9975585OtherUNIVERSAL HEALTHCARE
GA156961100OtherU.S. DEPT. OF LABOR
GA20-02624OtherUNITED HEALTHCARE
GAP00296749OtherRAIL ROAD MEDICARE
GA000550338GMedicaid
GA52267829-002OtherBLUE CROSS BLUE SHIELD
GA156961100OtherU.S. DEPT. OF LABOR