Provider Demographics
NPI:1619932993
Name:SMITH, KEVIN S (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
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:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1930 BISHOP LN
Practice Address - Street 2:STE 1017
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1921
Practice Address - Country:US
Practice Address - Phone:502-272-5064
Practice Address - Fax:502-272-5339
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051932A207R00000X
IL036-082153207R00000X
KY39134208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
049238OtherSIHO
IN200156690Medicaid
KYP00267326OtherRAILROAD MEDICARE - NICC
IL214881OtherMEDICARE GROUP PTAN
KYP00272398OtherRAILROAD MEDICARE - NICC
INP00838098OtherRAILROAD MEDICARE - NICC
000000382064OtherANTHEM
KY64094048Medicaid
KY0361957Medicare PIN
IL214881OtherMEDICARE GROUP PTAN
IN200156690Medicaid