Provider Demographics
NPI:1801822747
Name:SMITH, KENNETH B (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-7500
Mailing Address - Fax:636-239-2836
Practice Address - Street 1:901 PATIENTS FIRST DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-239-7500
Practice Address - Fax:636-239-2836
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7025207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202116802Medicaid
110166321OtherRAILROAD MEDICARE
MOP01135273OtherRAILROAD MEDICARE
MO202116802Medicaid
012012943Medicare PIN
MOP01135273OtherRAILROAD MEDICARE