Provider Demographics
NPI:1891849964
Name:KENNETH R SMITH MD
Entity Type:Organization
Organization Name:KENNETH R SMITH MD
Other - Org Name:INTERNAL MEDICINE OF BRIDGEVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-337-3300
Mailing Address - Street 1:8991 REDDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19933-4746
Mailing Address - Country:US
Mailing Address - Phone:302-337-3300
Mailing Address - Fax:302-337-8072
Practice Address - Street 1:8991 REDDEN RD
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:DE
Practice Address - Zip Code:19933-4746
Practice Address - Country:US
Practice Address - Phone:302-337-3300
Practice Address - Fax:302-337-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0003941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE751216Medicare ID - Type Unspecified