Provider Demographics
NPI:1013092808
Name:SMITH, WILLIAM D JR (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-647-4085
Mailing Address - Fax:502-647-4098
Practice Address - Street 1:727 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1660
Practice Address - Country:US
Practice Address - Phone:502-647-4085
Practice Address - Fax:502-647-4098
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200902460AMedicaid
KY7100045920Medicaid
KYP60416Medicare UPIN
KY7100045920Medicaid
KYP00680830Medicare PIN