Provider Demographics
NPI:1023060373
Name:SMITH, WADE G (DO)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:1343 N FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1422
Practice Address - Country:US
Practice Address - Phone:937-390-5000
Practice Address - Fax:937-390-5526
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007103S207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000315976OtherANTHEM
OH000000548866OtherANTHEM
P00054518OtherRAILROAD MEDICARE
000000302741OtherANTHEM BCBS
OH2126658Medicaid
OH000000543484OtherANTHEM
IN200915100Medicaid
OH000000548866OtherANTHEM
000000302741OtherANTHEM BCBS
OH0899988Medicare PIN
OH4228981Medicare PIN
IN200915100Medicaid
OH000000543484OtherANTHEM
SM0899986Medicare PIN