Basic Information
| Provider Information | |||||||||
| NPI: | 1255369732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 9548392569 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 JESSE JEWELL PKWY SE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702977277 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 039472 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00824271A | 05 | GA | MEDICAID | 000824271B | 05 | GA | MEDICAID |