Provider Demographics
NPI:1487812889
Name:SMITH, EMMALEIGH MADELINE
Entity type:Individual
Prefix:
First Name:EMMALEIGH
Middle Name:MADELINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6387 RAMSEY ST UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6387 RAMSEY ST UNIT 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-9442
Practice Address - Country:US
Practice Address - Phone:910-615-3879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00991207Q00000X
MEMD19062207Q00000X
IL036128825207Q00000X
MI4301099755207Q00000X
HIMD-16422207Q00000X
MDD0077929207Q00000X
IN01066982A207Q00000X
WI56121-020207Q00000X
WAMD.MD.60636873207Q00000X
VA0101251943207Q00000X
ORMD155232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100017659Medicaid
IN000000966488OtherBCBS BMG CENTRAL
IN000000966491OtherBCBS MEDPOINT IRELAND
IN000000966489OtherBCBS BMG SOUTHEAST
IN000000966489OtherBCBS BMG SOUTHEAST
IN178410016Medicare PIN