Provider Demographics
NPI:1154327534
Name:SMITH, KENNETH GERALD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GERALD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:GERALD
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10012 KENNERLY RD STE 406
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-525-1224
Mailing Address - Fax:314-525-4957
Practice Address - Street 1:10012 KENNERLY RD STE 406
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-525-1224
Practice Address - Fax:314-525-4957
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116081208600000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG80324Medicare UPIN
MO053012295Medicare PIN