Provider Demographics
NPI:1831156306
Name:YVONNE L. SMITH MD PC
Entity type:Organization
Organization Name:YVONNE L. SMITH MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:770-964-7736
Mailing Address - Street 1:4910 JONESBORO ROAD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2085
Mailing Address - Country:US
Mailing Address - Phone:770-964-7736
Mailing Address - Fax:770-306-1726
Practice Address - Street 1:4910 JONESBORO ROAD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2085
Practice Address - Country:US
Practice Address - Phone:770-964-7736
Practice Address - Fax:770-306-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042443208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0007340271Medicaid
E62538Medicare UPIN
GA11BDRKTMedicare PIN
11BDRKTMedicare ID - Type Unspecified