Provider Demographics
NPI:1275646473
Name:SMITH, KINIM I (MD)
Entity Type:Individual
Prefix:DR
First Name:KINIM
Middle Name:I
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3817 MCMASTERS AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2488
Mailing Address - Country:US
Mailing Address - Phone:573-221-0304
Mailing Address - Fax:573-221-0308
Practice Address - Street 1:3817 MCMASTERS AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2488
Practice Address - Country:US
Practice Address - Phone:573-221-0304
Practice Address - Fax:573-221-0308
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO119287174400000X, 207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204666317Medicaid
MO000095293OtherMEDICARE PTAN
MOMA1381OtherMEDICARE PTAN