Healthcare Provider Details

I. General information

NPI: 1972583607
Provider Name (Legal Business Name): CARL EDWIN SMITH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PROFESSIONAL LANE STE 201
HARLAN KY
40831-2603
US

IV. Provider business mailing address

120 PROFESSIONAL LANE STE 201
HARLAN KY
40831-2603
US

V. Phone/Fax

Practice location:
  • Phone: 606-573-1004
  • Fax: 606-573-0059
Mailing address:
  • Phone: 606-573-1004
  • Fax: 606-573-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24028
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: