Basic Information
Provider Information | |||||||||
NPI: | 1841392883 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 775383 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606775383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123753000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3015 10TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 472017090 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123728426 | ||||||||
FaxNumber: | 8123787777 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2006 | ||||||||
LastUpdateDate: | 10/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01057282 | IN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 040518 | 01 | IN | SIHO | OTHER | 351907774014 | 01 | IN | TRICARE | OTHER | 351907774NS | 01 | IN | DONLEY | OTHER | 200122370 | 05 | IN |   | MEDICAID | 000000984122 | 01 | IN | ANTHEM PIN | OTHER | 351907774116 | 01 | IN | CARESOURCE | OTHER | 000000330916 | 01 | IN | BLUE CROSS | OTHER | 1518068527 | 01 |   | GROUP NPI | OTHER |