Basic Information
| Provider Information | |||||||||
| NPI: | 1336340454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025882348 | ||||||||
| FaxNumber: | 5025882334 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAY ST | ||||||||
| Address2: | STE 802 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025882348 | ||||||||
| FaxNumber: | 5025882334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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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 | 208000000X | 41086 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 41086 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 7100021340 | 05 | KY | MEDICAID | 200890490 | 05 | IN | MEDICAID |