MEDICARE: CLEANSLATE MEDICAL GROUP OF KENTUCKY PLLC

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	207RA0401X	Addiction Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1538600630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEANSLATE MEDICAL GROUP OF KENTUCKY PLLC

Provider Business Mailing Address
First Line	:	8 CADILLAC DR STE 180
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5393
Country	:	US
Telephone Number	:	154-250-0220
Fax Number	:	833-279-7074

Provider Business Practice Location Address
First Line	:	6801 DIXIE HWY STE 132
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40258-3952
Country	:	US
Telephone Number	:	502-657-2701
Fax Number	:	833-279-7074

Authorized Official
Title or Position	:	CFO
Name	:	MATTHEW PHILIP SMOLAREK
Credential	:
Telephone Number	:	412-999-5188

Provider Enumeration Date	:	03/09/2017
Last Update Date	:	05/08/2025

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