Provider Demographics
NPI:1639196231
Name:SMITH, TABATHIA A (MD)
Entity Type:Individual
Prefix:
First Name:TABATHIA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:888-861-8740
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:1500 N 28TH ST
Practice Address - Street 2:EMERGENCY DEPT.
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5332
Practice Address - Country:US
Practice Address - Phone:804-225-1780
Practice Address - Fax:804-225-1705
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101055832207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005844231Medicaid
VA005844673Medicaid
11196250OtherCAQH
VA005844240Medicaid
VA005834864Medicaid
VA005844240Medicaid
VA930001789Medicare PIN
VA930001679Medicare PIN
VA005834864Medicaid
VA930001790Medicare PIN