Provider Demographics
NPI:1194725424
Name:SMITH, KEVIN L (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 7366
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7366
Mailing Address - Country:US
Mailing Address - Phone:320-257-5595
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-257-5595
Practice Address - Fax:320-257-5596
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-08-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN420882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16-02418OtherMEDICA
MNHP38324OtherHEALTH PARTNERS
MN128440C561OtherUCARE OF MINNESOTA
MN300138882OtherRAILROAD MEDICARE
MN883131OtherARAZ/ AMERICA'S PPO
MN411772562OtherTRICARE
MN411772562OtherGREATWEST HEALTHCARE
MN67G97SMOtherBLUE CROSS BLUE SHIELD
MN627622900Medicaid
MN965251022160OtherPREFERRED ONE
MN411772562OtherGREATWEST HEALTHCARE
MNHP38324OtherHEALTH PARTNERS