1790866044 NPI number — KENDRA MAE BLACK-SMITH MD

Table of content: KENDRA MAE BLACK-SMITH MD (NPI 1790866044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790866044 NPI number — KENDRA MAE BLACK-SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK-SMITH
Provider First Name:
KENDRA
Provider Middle Name:
MAE
Provider Name Prefix Text:
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:
SMITH
Provider Other First Name:
KENDRA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790866044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2003 KOOTENAI HEALTH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-6051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-625-5059
Provider Business Mailing Address Fax Number:
208-625-5731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2003 KOOTENAI HEALTH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-625-5185
Provider Business Practice Location Address Fax Number:
208-625-6892
Provider Enumeration Date:
10/17/2006

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: 2080N0001X , with the licence number:  MD00039197 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: M14495 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 272030 . This is a "INTERNAL ID-MOTOR VEHICLE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8269235 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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