1578858742 NPI number — MR. JERRY SOLON SMITH PA-C

Table of content: MR. JERRY SOLON SMITH PA-C (NPI 1578858742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578858742 NPI number — MR. JERRY SOLON SMITH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JERRY
Provider Middle Name:
SOLON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1578858742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 LINCOLN DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERRIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-997-6800
Provider Business Mailing Address Fax Number:
618-997-1187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4787 ALBEN BARKLEY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-442-9461
Provider Business Practice Location Address Fax Number:
270-441-0079
Provider Enumeration Date:
06/15/2011

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: 363AM0700X , with the licence number:  PA1645 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100226410 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com