Basic Information
| Provider Information | |||||||||
| NPI: | 1588755664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | IRVIN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2507 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704428228 | ||||||||
| FaxNumber: | 2704429566 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705752100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207L00000X | 21249 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 64212491 | 05 | KY | MEDICAID |