1013117159 NPI number — EMILY SMITH O.D.

Table of content: EMILY SMITH O.D. (NPI 1013117159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013117159 NPI number — EMILY SMITH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
EMILY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1013117159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
904 W SPRINGFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAYLORVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62568-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-287-2020
Provider Business Mailing Address Fax Number:
217-824-2228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 W DEYOUNG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-4437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-993-5686
Provider Business Practice Location Address Fax Number:
618-997-6250
Provider Enumeration Date:
07/18/2007

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: 152W00000X , with the licence number:  046-009974 , 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: 0814870032 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00454765, CB9582 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0814870028 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0814870001 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL9974 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0814870027 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046009974 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0814870029 . This is a "MEDICARE NSC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 135537 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".




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