Provider Demographics
NPI:1124029392
Name:SMITH, PERRY M (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:M
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 1:1309 POLK ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3618
Mailing Address - Country:US
Mailing Address - Phone:620-792-5341
Mailing Address - Fax:620-792-3702
Practice Address - Street 1:1309 POLK ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3618
Practice Address - Country:US
Practice Address - Phone:620-792-5341
Practice Address - Fax:620-792-3702
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-17929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017892OtherBLUE SHIELD
KS017892Medicare ID - Type Unspecified
KS017892OtherBLUE SHIELD