Healthcare Provider Details

I. General information

NPI: 1477703619
Provider Name (Legal Business Name): GREGORY D. SMITH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 RING RD STE 200
ELIZABETHTOWN KY
42701-5913
US

IV. Provider business mailing address

53 MAYAPPLE LN
ELIZABETHTOWN KY
42701-8944
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5926
  • Fax: 270-763-0051
Mailing address:
  • Phone: 270-765-5926
  • Fax: 270-763-0051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3007523
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number38746
License Number StateKY

VIII. Authorized Official

Name: DR. GREGORY D. SMITH
Title or Position: OWNER
Credential: MD
Phone: 270-765-5926