Provider Demographics
NPI:1457323909
Name:SMITH, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
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:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-660-6148
Mailing Address - Fax:706-660-2843
Practice Address - Street 1:1831 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8915
Practice Address - Country:US
Practice Address - Phone:706-320-8660
Practice Address - Fax:706-320-8664
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048722208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000879029BOtherMEDICAID-OFFICE
AL154859OtherMEDICAID-MMC
GA20046782OtherRAILROAD MEDICARE
GA000879029DOtherMEDICAID-MMC
AL009931860Medicaid
GA52262489-003OtherBCBS
GA52262489-005OtherBCBS
AL600-11156OtherBCBS
GA000879029COtherMEDICAID-DSH
GA000879029AMedicaid
GA000879029EOtherMEDICAID-NSMC
AL600-96706OtherBCBS
GA52262489-003OtherBCBS
GA000879029EOtherMEDICAID-NSMC
AL154859OtherMEDICAID-MMC