Provider Demographics
NPI:1366412033
Name:SMITH, REBECCA L (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 FIRST BAXTER XING
Mailing Address - Street 2:STE 101
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8919
Mailing Address - Country:US
Mailing Address - Phone:803-802-3376
Mailing Address - Fax:
Practice Address - Street 1:1700 FIRST BAXTER XING
Practice Address - Street 2:STE 101
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8919
Practice Address - Country:US
Practice Address - Phone:803-802-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC9901324207N00000X, 207NP0225X
SC15514207NP0225X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG04388Medicare UPIN