Provider Demographics
NPI:1427027192
Name:BOSTON, TISHA SMITH (MD)
Entity type:Individual
Prefix:DR
First Name:TISHA
Middle Name:SMITH
Last Name:BOSTON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6697
Mailing Address - Fax:
Practice Address - Street 1:3209 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6930
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-758-0106
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC213316Medicaid
SCH294535770Medicare ID - Type Unspecified
SCH29453Medicare UPIN