Provider Demographics
NPI:1154404150
Name:SMITH, KATHIE G (DC)
Entity type:Individual
Prefix:
First Name:KATHIE
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:111 N HARDIN
Mailing Address - City:ASHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62612-0385
Mailing Address - Country:US
Mailing Address - Phone:217-476-6547
Mailing Address - Fax:217-476-3546
Practice Address - Street 1:111 N HARDIN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:IL
Practice Address - Zip Code:62612-0385
Practice Address - Country:US
Practice Address - Phone:217-476-6547
Practice Address - Fax:217-476-3546
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
982005OtherBLUE CROSS BLUE SHIELD OF
T38485Medicare UPIN
IL748890Medicare ID - Type Unspecified