Provider Demographics
NPI:1992062020
Name:SMITH, KEVIN
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 7TH RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-2568
Mailing Address - Country:US
Mailing Address - Phone:901-386-8539
Mailing Address - Fax:
Practice Address - Street 1:1900 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-818-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000158867163W00000X
TNAPN 16753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1992062020OtherCHAMPUS/TRICARE
AR192893001Medicaid
MS09552701Medicaid
TN1528772Medicaid
TN4327295OtherBCBST
AR192893001Medicaid