Provider Demographics
NPI:1598717894
Name:SMITH, JIMMY SHAUN (DO)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:SHAUN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 570
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-293-4925
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE STREET
Practice Address - Street 2:G100 GILL HEART INSTITUTE
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-0295
Practice Address - Fax:859-323-1256
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02968207RC0200X, 207RP1001X, 207P00000X
KYTP048207R00000X
OH34009306207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201032990Medicaid
OHPENDINGMedicaid
KY64121767Medicaid
KY64121767Medicaid