Provider Demographics
NPI:1649222928
Name:SMITH, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:615 WESLEY DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-571-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19374207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110176601OtherRAILROAD MCARE
SC193748Medicaid
SCP00727247OtherRAILROAD MEDICARE ID-RSFPP
SC110176601OtherRAILROAD MCARE
SCG649306795Medicare UPIN
SCG649304958Medicare UPIN