1407009103 NPI number — PAMELA E SMITH MD MPH CHES SC

Table of content: (NPI 1407009103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407009103 NPI number — PAMELA E SMITH MD MPH CHES SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAMELA E SMITH MD MPH CHES SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1407009103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 S AVERS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60623-2450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-542-0517
Provider Business Mailing Address Fax Number:
773-522-3637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 S AVERS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60623-2450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-542-0517
Provider Business Practice Location Address Fax Number:
773-522-3637
Provider Enumeration Date:
10/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
ELISE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-542-0517

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  036062316 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036062316 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VB0002X , with the licence number: 036062316 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0901X , with the licence number: 036062316 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , with the licence number: 036062316 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 036062316 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: C42702 . This is a "UPIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036062316 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".