Provider Demographics
NPI:1871621474
Name:SMITH, SUSAN J (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:SMITH
Other - Last Name:STEFANIUK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5607
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:772 MADDOX DR STE 122
Practice Address - Street 2:
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8196
Practice Address - Country:US
Practice Address - Phone:706-635-6898
Practice Address - Fax:706-635-6885
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030547207Q00000X, 207Q00000X, 207Q00000X
TNMD0000041060390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0577260001OtherDMERC NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
OR930635514OtherGROUP NBMC TAX ID
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORR141752Medicare PIN
TN3000596Medicare PIN