MEDICARE: KEVIN CHARLES SMITH D.O.

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	207Q00000X	Family Medicine Physician	03401	KY
2	207P00000X	Emergency Medicine Physician	03401	KY

General Provider Information

NPI Number	:	1972592038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CHARLES SMITH D.O.

Provider Business Mailing Address
First Line	:	2250 LEESTOWN RD
Second Line	:	ROOM 217
City	:	LEXINGTON
State	:	KY
Zip	:	40511
Country	:	US
Telephone Number	:	859-233-4511
Fax Number	:	859-281-3928

Provider Business Practice Location Address
First Line	:	289 IRELAND AVE
Second Line	:
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5111
Country	:	US
Telephone Number	:	502-624-9795
Fax Number	:

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

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	10/20/2023

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