Basic Information
| Provider Information | |||||||||
| NPI: | 1487630091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5363 SHADOW HILL CT | ||||||||
| Address2: | |||||||||
| City: | TAYLOR MILL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595817952 | ||||||||
| FaxNumber: | 8595817952 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 258 | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1054975 | KY | N | Nursing Service Providers | Registered Nurse | 367500000X | 037860 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 74097817 | 05 | KY | MEDICAID | 2166454 | 05 | OH | MEDICAID | 000000389807 | 01 | ANTHEM | OTHER |