Basic Information
| Provider Information | |||||||||
| NPI: | 1992749873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 WILSON AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403831947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598790111 | ||||||||
| FaxNumber: | 8598790363 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 WILSON AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403831947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598790111 | ||||||||
| FaxNumber: | 8598790363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 40454 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 40454 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100003320 | 05 | KY | MEDICAID |