Provider Demographics
NPI:1578508974
Name:SMALLWOOD, MELANIE ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANDREA
Last Name:SMALLWOOD
Suffix:
Gender:F
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:9880 ANGIES WAY
Practice Address - Street 2:SUITE 420
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2851
Practice Address - Country:US
Practice Address - Phone:502-394-6200
Practice Address - Fax:502-394-6210
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39555208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
082779OtherSIHO - NMA
2819054000OtherPAD - NMA
000000501968OtherANTHEM - NMA
50013988OtherPASSPORT - NMA
KY64131170Medicaid
50013988OtherPASSPORT - NMA
KY64131170Medicaid