Basic Information
| Provider Information | |||||||||
| NPI: | 1770535080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | WADE | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 695 DUG HILL RD | ||||||||
| Address2: | |||||||||
| City: | BROWNSBORO | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357419212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565348171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4601 WHITESBURG DR S | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358021676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568801050 | ||||||||
| FaxNumber: | 2568807477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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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 | 207RI0011X | 24624 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 051551866 | 05 | AL | MEDICAID |