Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 21474 | KY |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 21474 | KY |
NPI | 1619948692 |
---|---|
Provider Name | John T. Small |
First Address | Campton, KY 41301-0757 |
Second Address | Haggerhill, KY 41222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 14/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000377498 | BLUECROSS BLUESHIELD (01) | KY |
1069188 | BRICKSTREET (01) | WV |
2624324 | (05) | OH |
3810004017 | (05) | WV |
5490 | MEDICARE GROUP (01) | KY |
64072978 | (05) | KY |
C68647 | (02) |