Provider Demographics
NPI:1952495517
Name:SMITH, ROBERT JAMES (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 HILLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-6769
Mailing Address - Country:US
Mailing Address - Phone:854-901-0433
Mailing Address - Fax:
Practice Address - Street 1:101 BRIGHTWATER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-8275
Practice Address - Country:US
Practice Address - Phone:203-906-6799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003476363A00000X
SC4504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R56764Medicare UPIN