Provider Demographics
NPI:1720005325
Name:SMITH, RAY C III (MD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:C
Last Name:SMITH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-547-5345
Mailing Address - Fax:317-962-4343
Practice Address - Street 1:1606 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2706
Practice Address - Country:US
Practice Address - Phone:812-442-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033441A207P00000X
MI4301042616207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100388340Medicaid
IN930040138OtherRAILROAD MEDICARE
IN131180YMedicare PIN
IN941020J4Medicare PIN
IN100388340Medicaid