Basic Information
| Provider Information | |||||||||
| NPI: | 1578858742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | SOLON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 LINCOLN DRIVE | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
| FaxNumber: | 6189971187 | ||||||||
| Practice Location | |||||||||
| Address1: | 4787 ALBEN BARKLEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704429461 | ||||||||
| FaxNumber: | 2704410079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 06/08/2015 | ||||||||
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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 | 363AM0700X | PA1645 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7100226410 | 05 | KY | MEDICAID |