Provider Demographics
NPI:1861479974
Name:SMITH, RYAN WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WESLEY
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 1427
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 SURGEONS DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-504-7194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47099207L00000X
SC29753207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN777643800Medicaid
MN050001755Medicare ID - Type Unspecified
SCAA20617226Medicare PIN
SCAA20618721Medicare PIN
MN777643800Medicaid