Provider Demographics
NPI:1770979221
Name:SMITH, BLAKE GAITHER
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:GAITHER
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 19TH STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35249
Mailing Address - Country:US
Mailing Address - Phone:731-446-1954
Mailing Address - Fax:
Practice Address - Street 1:2000 6TH AVE S FL 4
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-2110
Practice Address - Country:US
Practice Address - Phone:205-934-7114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL35621207RC0001X
390200000X
ALMD.35621207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program