MEDICARE: DR. KENNETH GERALD SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	116081	MO

General Provider Information

NPI Number	:	1154327534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH GERALD SMITH M.D.

Provider Business Mailing Address
First Line	:	10012 KENNERLY RD STE 406
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2197
Country	:	US
Telephone Number	:	314-525-1224
Fax Number	:	314-525-4957

Provider Business Practice Location Address
First Line	:	10012 KENNERLY RD STE 406
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2197
Country	:	US
Telephone Number	:	314-525-1224
Fax Number	:	314-525-4957

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	01/06/2022

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