Provider Demographics
NPI:1669403093
Name:SMITH MAXEY, SHANNON LEA (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:SMITH MAXEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:2585 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703
Practice Address - Country:US
Practice Address - Phone:304-781-5138
Practice Address - Fax:304-697-2086
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22344208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005791Medicaid
OH2667038Medicaid
WV3810005791Medicaid
WVWV3390BMedicare PIN
WVI56751Medicare UPIN
OH2667038Medicaid
WVWV3990AMedicare PIN