Healthcare Provider Details

I. General information

NPI: 1992749873
Provider Name (Legal Business Name): BRIAN A SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 WILSON AVE FIRST FLOOR
VERSAILLES KY
40383-1947
US

IV. Provider business mailing address

460 WILSON AVE FIRST FLOOR
VERSAILLES KY
40383-1947
US

V. Phone/Fax

Practice location:
  • Phone: 859-879-0111
  • Fax: 859-879-0363
Mailing address:
  • Phone: 859-879-0111
  • Fax: 859-879-0363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number40454
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40454
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: