Provider Demographics
NPI:1881615235
Name:SMITH, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SMITH
Suffix:
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 1:13117 EASTPOINT PARK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4193
Mailing Address - Country:US
Mailing Address - Phone:502-238-2801
Mailing Address - Fax:502-238-2835
Practice Address - Street 1:12010 SHELBYVILLE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1054
Practice Address - Country:US
Practice Address - Phone:502-238-2800
Practice Address - Fax:502-238-2805
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20296207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000182121OtherBCBS
KY64202963Medicaid
P00239216OtherRR MCR
KY64202963Medicaid
000000182121OtherBCBS