1043327141 NPI number — MARK L SMITH MD

Table of content: MARK L SMITH MD (NPI 1043327141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043327141 NPI number — MARK L SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043327141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-549-5361
Provider Business Mailing Address Fax Number:
618-529-0568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 RUSHING DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-943-3300
Provider Business Practice Location Address Fax Number:
618-997-6626
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036067104 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10019630 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 115574 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036067104 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 033352 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080075455 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 143870 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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