Provider Demographics
NPI:1962400648
Name:SMITH, BRUCE C (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:KY
Mailing Address - Zip Code:42031-1305
Mailing Address - Country:US
Mailing Address - Phone:270-653-0220
Mailing Address - Fax:270-653-0221
Practice Address - Street 1:423 W CLAY ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:KY
Practice Address - Zip Code:42031-1305
Practice Address - Country:US
Practice Address - Phone:270-653-0220
Practice Address - Fax:270-653-0221
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64172745Medicaid
KY000000333811OtherANTHEM
KY64172745Medicaid
KYC63973Medicare UPIN