Provider Demographics
NPI:1841392883
Name:SMITH, KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:SMITH
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 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:3015 10TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-7090
Practice Address - Country:US
Practice Address - Phone:812-372-8426
Practice Address - Fax:812-378-7777
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200122370Medicaid
IN040518OtherSIHO
1518068527OtherGROUP NPI
IN351907774014OtherTRICARE
IN351907774116OtherCARESOURCE
IN351907774NSOtherDONLEY
IN000000330916OtherBLUE CROSS
IN000000984122OtherANTHEM PIN
IN000000984122OtherANTHEM PIN
1518068527OtherGROUP NPI
IN000000330916OtherBLUE CROSS