Provider Demographics
NPI:1356029086
Name:SMITH, KEVIN B
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W 23RD ST # 200
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-1259
Mailing Address - Country:US
Mailing Address - Phone:816-838-2603
Mailing Address - Fax:816-908-9210
Practice Address - Street 1:117 W 23RD ST # 200
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-1259
Practice Address - Country:US
Practice Address - Phone:816-838-2603
Practice Address - Fax:816-908-9210
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO93-2299846Medicaid