Healthcare Provider Details

I. General information

NPI: 1093376568
Provider Name (Legal Business Name): ELIZABETH ANNE SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

910 W LAKE ST UNIT 6M
CHICAGO IL
60607-1737
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 651-528-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036165357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: