Healthcare Provider Details

I. General information

NPI: 1629563747
Provider Name (Legal Business Name): KHERCIE SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2018
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 MARIE LANGDON DR
MANCHESTER KY
40962-6329
US

IV. Provider business mailing address

330 BARCLAY AVE NE
GRAND RAPIDS MI
49503-2556
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-4080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301116055
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: