MEDICARE: DR. JAMES RALPH SMITH PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071-003744	IL

General Provider Information

NPI Number	:	1659364180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES RALPH SMITH PH.D.

Provider Business Mailing Address
First Line	:	2506 GALEN DR
Second Line	:	SUITE 103
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-7046
Country	:	US
Telephone Number	:	217-398-0744
Fax Number	:	217-398-0778

Provider Business Practice Location Address
First Line	:	2506 GALEN DR
Second Line	:	SUITE 103
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-7046
Country	:	US
Telephone Number	:	217-398-0744
Fax Number	:	217-398-0778

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	09/17/2012

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