1841392883 NPI number — DR. KATHLEEN SMITH MD

Table of content: DR. KATHLEEN SMITH MD (NPI 1841392883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841392883 NPI number — DR. KATHLEEN SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841392883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 775383
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-5383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-376-5315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47201-7090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-372-8426
Provider Business Practice Location Address Fax Number:
812-378-7777
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01057282 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200122370 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040518 . This is a "SIHO" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1518068527 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 351907774014 . This is a "TRICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351907774116 . This is a "CARESOURCE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351907774NS . This is a "DONLEY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000330916 . This is a "BLUE CROSS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000984122 . This is a "ANTHEM PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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