Provider Demographics
NPI:1982668612
Name:SMITH, KELLIE K (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:K
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 1:9050 MONTGOMERY ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7740
Mailing Address - Country:US
Mailing Address - Phone:513-631-6963
Mailing Address - Fax:513-631-1970
Practice Address - Street 1:9050 MONTGOMERY ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-7740
Practice Address - Country:US
Practice Address - Phone:513-631-6963
Practice Address - Fax:513-631-1970
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065777207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0996052Medicaid
OHP00790119OtherRAILROAD MEDICARE PIN
OH0760188Medicare PIN
OH0760185Medicare PIN
OH0760187Medicare PIN
OH0760186Medicare PIN
OH0996052Medicaid