Basic Information
| Provider Information | |||||||||
| NPI: | 1578521019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 MEDICAL CIRCLE | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067846641 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 MEDICAL CIRCLE | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067846641 | ||||||||
| FaxNumber: | 6067802373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 36792 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 64038888 | 05 | KY | MEDICAID |