1679861371 NPI number — JAMIERE Y SMITH MD SC

Table of content: (NPI 1679861371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679861371 NPI number — JAMIERE Y SMITH MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMIERE Y SMITH MD 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:
1679861371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5312 S INGLESIDE 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:
60615-4310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-779-8285
Provider Business Mailing Address Fax Number:
773-324-2355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9951 SOUTH HALSTED STREET
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:
60628-1035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-779-8285
Provider Business Practice Location Address Fax Number:
773-779-8240
Provider Enumeration Date:
07/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JAMIERE
Authorized Official Middle Name:
YOLANDE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-779-8285

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  036087325 , 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: 214485 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036087325 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com