Provider Demographics
NPI:1861582934
Name:SMITH, GREGORY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
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:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-921-4811
Mailing Address - Fax:770-921-7943
Practice Address - Street 1:4030 LAWRENCEVILLE HWY NW
Practice Address - Street 2:STE. 9
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3011
Practice Address - Country:US
Practice Address - Phone:770-921-4811
Practice Address - Fax:770-921-7943
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1609816123OtherGEORGIA CLINIC PC GROUP NPI #
GA003124308CMedicaid
GA003124308AMedicaid
GA003124308BMedicaid
GA003124308AMedicaid
GA003124308CMedicaid