Provider Demographics
NPI:1720291966
Name:THIBAULT, ERIN SMITH (MD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:SMITH
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-497-5355
Mailing Address - Fax:423-308-0281
Practice Address - Street 1:1651 GUNBARREL RD STE 102A
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3289
Practice Address - Country:US
Practice Address - Phone:423-468-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59215207ZP0102X
LAMD.204117207ZP0102X
TN58784207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2154800Medicaid
LA4Q451Medicare PIN