Provider Demographics
NPI: | 1164610101 |
---|---|
Name: | SMITH, CHRISTOPHER MATTHEW (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CHRISTOPHER |
Middle Name: | MATTHEW |
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: | 223 EXECUTIVE PARK |
Mailing Address - Street 2: | |
Mailing Address - City: | LOUISVILLE |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40207-4202 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 502-619-4131 |
Mailing Address - Fax: | 502-919-9780 |
Practice Address - Street 1: | 13402 CREEKVIEW RD |
Practice Address - Street 2: | |
Practice Address - City: | PROSPECT |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40059-9028 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-619-4131 |
Practice Address - Fax: | 502-919-9780 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-10-03 |
Last Update Date: | 2023-10-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 43824 | 207P00000X, 207PH0002X, 208D00000X |
IN | 01076713A | 207PH0002X, 208D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | |
No | 207PH0002X | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine |