Healthcare Provider Details

I. General information

NPI: 1891849964
Provider Name (Legal Business Name): KENNETH R SMITH MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8991 REDDEN RD
BRIDGEVILLE DE
19933-4746
US

IV. Provider business mailing address

8991 REDDEN RD
BRIDGEVILLE DE
19933-4746
US

V. Phone/Fax

Practice location:
  • Phone: 302-337-3300
  • Fax: 302-337-8072
Mailing address:
  • Phone: 302-337-3300
  • Fax: 302-337-8072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0003941
License Number StateDE

VIII. Authorized Official

Name: DR. KENNETH R SMITH
Title or Position: OWNER
Credential: MD
Phone: 302-337-3300