Basic Information
| Provider Information | |||||||||
| NPI: | 1225028897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636961 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815130 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 HWY 121 N. BYPASS | ||||||||
| Address2: | SUITE I | ||||||||
| City: | MURRY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702261118 | ||||||||
| FaxNumber: | 2702261119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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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 | 363L00000X | 3003886 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3003886 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000732995 | 01 | KY | BCBS | OTHER | 7100157310 | 05 | KY | MEDICAID | P00956479 | 01 | KY | RAILROAD MEDICARE | OTHER |