Provider Demographics
NPI:1780771824
Name:SMITH, PAMELA ANN (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
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 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-780-0474
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1759
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:270-780-0474
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50487207RH0003X
MT26256207RH0003X
KYTP779207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100460170Medicaid