Provider Demographics
NPI:1003895046
Name:SMITH, KEVIN G (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-1773
Mailing Address - Country:US
Mailing Address - Phone:724-588-6500
Mailing Address - Fax:724-588-2257
Practice Address - Street 1:408 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1773
Practice Address - Country:US
Practice Address - Phone:724-588-6500
Practice Address - Fax:724-588-2257
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040603E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012122300001Medicaid
PA0012122300001Medicaid
PAE27390Medicare UPIN