Provider Demographics
NPI:1225032758
Name:SMITH, JENNIFER M (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 11137
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1137
Mailing Address - Country:US
Mailing Address - Phone:304-344-3457
Mailing Address - Fax:304-344-3480
Practice Address - Street 1:1120 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2400
Practice Address - Country:US
Practice Address - Phone:304-344-3457
Practice Address - Fax:304-344-3480
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV215102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0130753OtherUMWA
WV550516458OtherACORDIA NATIONAL PEIA
WVI07409OtherBRICKSTREET INSURANCE
WV14175Medicaid
OH2479401Medicaid
WV3810000119Medicaid
WV55-0516458OtherGROUP FEIN #
WV001718811OtherFREEDOM BLUE & MS BC BS
WV020011800OtherFEDERAL BLACK LUNG
WV550516458Medicaid
WV14193OtherCARELINK & CARELINK PEIA
WV151237200OtherUS DOL & US POSTAL COMP
KY64083843Medicaid
WVIO7409Medicare UPIN
OH2479401Medicaid
KY64083843Medicaid
WV55-0516458OtherGROUP FEIN #