Provider Demographics
NPI:1700877719
Name:SMITH, REGINALD M (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:M
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:P.O. BOX 175
Mailing Address - Street 2:
Mailing Address - City:MOODY
Mailing Address - State:AL
Mailing Address - Zip Code:35004-0175
Mailing Address - Country:US
Mailing Address - Phone:205-640-0001
Mailing Address - Fax:205-640-1557
Practice Address - Street 1:2345 MOODY PARKWAY
Practice Address - Street 2:STE 204
Practice Address - City:MOODY
Practice Address - State:AL
Practice Address - Zip Code:35004-3039
Practice Address - Country:US
Practice Address - Phone:205-640-0001
Practice Address - Fax:205-640-1557
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27262207R00000X, 208VP0000X
MO2002027127207R00000X
TN0000032235207R00000X
ALMD.27262207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051538695Medicaid
AL051538695OtherBCBS
AL051538695OtherBCBS
AL051538695Medicaid
AL051538695Medicare PIN