Smith, Jerry Randolph

Smith, Jerry Randolph is an individual health care provider with primary practice located at 3015 Wilson Ave Park Duvalle Cnc, Louisville KY 40211. He recently has only one registered license in Allopathic & Osteopathic Physicians / Family Medicine, which is considered as his primary health care specialty. Smith, Jerry Randolph can be contacted via phone (502) 774-4401.

Contact Information

Primary practice address
3015 Wilson Ave Park Duvalle Cnc Louisville KY 40211
Phone: (502) 774-4401
Fax: (502) 772-4783
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Family Medicine 207Q00000X 18109 Kentucky

Profile Details

NPI number 1003989708
LBN Legal business name Smith, Jerry Randolph
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Nov 17th, 2006
Last updated Jul 25th, 2012 - about 12 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1003989708 NPPES
Kentucky MEDICAID 64181092

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