Provider Demographics
NPI:1811957384
Name:SMITH, JERRY LEE (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
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 1:1 SISKIN PLZ STE 101
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-1306
Mailing Address - Country:US
Mailing Address - Phone:423-803-2226
Mailing Address - Fax:423-803-2222
Practice Address - Street 1:1 SISKIN PLZ STE 101
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1306
Practice Address - Country:US
Practice Address - Phone:423-803-2226
Practice Address - Fax:423-803-2222
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026739208100000X
GA0419602081P2900X
TNMD267392081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10076869OtherAMERIGROUP
TN4126985OtherBCBSTN
GA376910OtherWELLCARE
GA376910OtherWELLCARE
TN4126985OtherBCBSTN
GA25BBGBTMedicare PIN
GA10076869OtherAMERIGROUP
TN3096045Medicaid
TNP00319076Medicare PIN