Provider Demographics
NPI:1093852642
Name:SMITH, KEVIN ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 2363
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2363
Mailing Address - Country:US
Mailing Address - Phone:843-724-2988
Mailing Address - Fax:843-805-6277
Practice Address - Street 1:316 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1113
Practice Address - Country:US
Practice Address - Phone:843-724-2988
Practice Address - Fax:843-805-6277
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC323732085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1093852642Medicaid
SCP00853366OtherRR MEDICARE
SCAA51054467Medicare PIN