Provider Demographics
NPI:1477703619
Name:GREGORY D. SMITH
Entity Type:Organization
Organization Name:GREGORY D. SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-765-5926
Mailing Address - Street 1:53 MAYAPPLE LN
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8944
Mailing Address - Country:US
Mailing Address - Phone:270-765-5926
Mailing Address - Fax:270-763-0051
Practice Address - Street 1:2412 RING RD STE 200
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5913
Practice Address - Country:US
Practice Address - Phone:270-765-5926
Practice Address - Fax:270-763-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38746207QA0401X
KY3007523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64087711Medicaid
KY64087711Medicaid
KY1968001Medicare PIN