Provider Demographics
NPI:1528297132
Name:JOHN M SMITH,M.D. P.S.C.
Entity type:Organization
Organization Name:JOHN M SMITH,M.D. P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-464-2946
Mailing Address - Street 1:PO BOX 170
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0170
Mailing Address - Country:US
Mailing Address - Phone:606-464-2946
Mailing Address - Fax:606-464-3502
Practice Address - Street 1:110 RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:BEATTYVILLE
Practice Address - State:KY
Practice Address - Zip Code:41311-0170
Practice Address - Country:US
Practice Address - Phone:606-464-2946
Practice Address - Fax:606-464-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64107287Medicaid
KY64107287Medicaid
P100023537Medicare PIN
1028501Medicare PIN