Healthcare Provider Details

I. General information

NPI: 1215914445
Provider Name (Legal Business Name): TRAVIS L SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1373 E STATE ROAD 62
MADISON IN
47250-7328
US

IV. Provider business mailing address

DEPT 86236 PO BOX 950195
LOUISVILLE KY
40295-0195
US

V. Phone/Fax

Practice location:
  • Phone: 812-801-0609
  • Fax: 812-801-0276
Mailing address:
  • Phone: 502-473-2100
  • Fax: 502-456-6461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3004523
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: