Provider Demographics
NPI:1659375269
Name:SMITH, GREGORY DALE (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2412 RING RD
Mailing Address - Street 2:STE 200
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5913
Mailing Address - Country:US
Mailing Address - Phone:270-765-5926
Mailing Address - Fax:270-763-0051
Practice Address - Street 1:2412 RING RD
Practice Address - Street 2:STE 200
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5913
Practice Address - Country:US
Practice Address - Phone:270-765-5926
Practice Address - Fax:270-763-0051
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2020-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY38746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2447320000OtherPASSPORT ADVANTAGE
KYP00169467OtherRAILROAD MEDICARE
KY000000337254OtherANTHEM BLUE CROSS
KY50006034OtherPASSPORT
KY64087711Medicaid
KY64087711Medicaid
1968001Medicare PIN
KY0788907Medicare ID - Type Unspecified