Healthcare Provider Details

I. General information

NPI: 1407009103
Provider Name (Legal Business Name): PAMELA E SMITH MD MPH CHES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S AVERS AVE
CHICAGO IL
60623-2450
US

IV. Provider business mailing address

1950 S AVERS AVE
CHICAGO IL
60623-2450
US

V. Phone/Fax

Practice location:
  • Phone: 773-542-0517
  • Fax: 773-522-3637
Mailing address:
  • Phone: 773-542-0517
  • Fax: 773-522-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036062316
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number036062316
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036062316
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number036062316
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036062316
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036062316
License Number StateIL

VIII. Authorized Official

Name: DR. PAMELA ELISE SMITH
Title or Position: PRESIDENT
Credential: MD
Phone: 773-542-0517