Basic Information
| Provider Information | |||||||||
| NPI: | 1053729756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALLWOOD | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | TESS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF KENTUCKY RM C-368 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 W SUN ST | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062072931 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2014 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R3624 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | TP593 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7100396490 | 05 | KY | MEDICAID |