Basic Information
| Provider Information | |||||||||
| NPI: | 1235176439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITHERS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 5TH ST S STE 306 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674170 | ||||||||
| FaxNumber: | 7277674346 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 5TH ST S STE 306 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674170 | ||||||||
| FaxNumber: | 7277674346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 216139 | MA | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | ME138873 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |