Healthcare Provider Details

I. General information

NPI: 1457323909
Provider Name (Legal Business Name): KENNETH L SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 5TH AVE
COLUMBUS GA
31904-8915
US

IV. Provider business mailing address

PO BOX 1038
COLUMBUS GA
31902-1038
US

V. Phone/Fax

Practice location:
  • Phone: 706-320-8660
  • Fax: 706-320-8664
Mailing address:
  • Phone: 706-660-6148
  • Fax: 706-660-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number048722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: