Healthcare Provider Details

I. General information

NPI: 1104960400
Provider Name (Legal Business Name): KELLY ANN SMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ANN STANICHUK D.O.

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OGDEN AVE
AURORA IL
60504-7222
US

IV. Provider business mailing address

2000 OGDEN AVE
AURORA IL
60504-7222
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-4810
  • Fax:
Mailing address:
  • Phone: 630-978-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036119988
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: