Provider Demographics
NPI:1518915594
Name:SMITH, KEVIN CHARLES (DC CCSP)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 HOLME AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152
Mailing Address - Country:US
Mailing Address - Phone:215-673-1113
Mailing Address - Fax:215-673-4941
Practice Address - Street 1:2875 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152
Practice Address - Country:US
Practice Address - Phone:215-673-1113
Practice Address - Fax:215-673-4941
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003171L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1514680Medicaid
PA0061028000OtherINDEPENDENCE BLUE CROSS
T28603Medicare UPIN
PA1514680Medicaid