Provider Demographics
NPI:1508966581
Name:SMITH, PHILIP G (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:G
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 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:1100 GOETHALS DRIVE 2ND FLOOR
Practice Address - Street 2:KADLEC CLINIC GENERAL & COLORECTAL SURGERY
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3304
Practice Address - Country:US
Practice Address - Phone:509-942-3185
Practice Address - Fax:509-946-1850
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60119652208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8563785Medicaid
CA00G848590Medicaid
WA258395OtherLABOR & INDUSTRIES
WA8563785Medicaid
CA00G848590Medicare ID - Type Unspecified
WA258395OtherLABOR & INDUSTRIES