Basic Information
| Provider Information | |||||||||
| NPI: | 1003907304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 EAST DUPONT ROAD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739728 | ||||||||
| FaxNumber: | 2604595664 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 EAST DUPONT ROAD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604891666 | ||||||||
| FaxNumber: | 2604893255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/03/2012 | ||||||||
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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 | 207RR0500X | 01022346 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 100108770A | 05 | IN | MEDICAID | 000000637485 | 01 | IN | ANTHEM | OTHER | 1866 | 01 | PHP | OTHER | 000000206530 | 01 | ANTHEM | OTHER | 4351567 | 01 | AETNA | OTHER | 000000006713 | 01 | M PLAN | OTHER | P00786840 | 01 | IN | R.R. MEDICARE | OTHER | 200092670 | 05 | IN | MEDICAID |