Provider Demographics
NPI:1033101126
Name:SMITH, KENNETH WAYNE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 SHERIDAN SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7399
Mailing Address - Country:US
Mailing Address - Phone:423-246-8061
Mailing Address - Fax:423-243-8278
Practice Address - Street 1:2 SHERIDAN SQ
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7399
Practice Address - Country:US
Practice Address - Phone:423-246-8061
Practice Address - Fax:423-243-8278
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD020006207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3047670Medicaid
TN3047670Medicare PIN
D42376Medicare UPIN