Provider Demographics
NPI:1588452114
Name:SMITH, CHARLES BRANNON IV
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRANNON
Last Name:SMITH
Suffix:IV
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2878 BLACKRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-5307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2878 BLACKRIDGE WAY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-5307
Practice Address - Country:US
Practice Address - Phone:205-381-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-182564163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse