Provider Demographics
NPI:1487630091
Name:SMITH, MICHAEL (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5363 SHADOW HILL CT
Mailing Address - Street 2:
Mailing Address - City:TAYLOR MILL
Mailing Address - State:KY
Mailing Address - Zip Code:41015
Mailing Address - Country:US
Mailing Address - Phone:859-581-7952
Mailing Address - Fax:859-581-7952
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:SUITE 258
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-301-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1054975163W00000X
KY037860367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74097817Medicaid
OH2166454Medicaid
000000389807OtherANTHEM
$$$$$$$$$00OtherBUREAU OF WORKERS COMP
OH2166454Medicaid
P00314169Medicare PIN
KY0693313Medicare ID - Type Unspecified