Healthcare Provider Details

I. General information

NPI: 1386784346
Provider Name (Legal Business Name): CARROLL EDWARD SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 S KING DR
CHICAGO IL
60653-2663
US

IV. Provider business mailing address

4900 S GREENWOOD AVE
CHICAGO IL
60615-2816
US

V. Phone/Fax

Practice location:
  • Phone: 773-624-0366
  • Fax: 773-624-0367
Mailing address:
  • Phone: 773-285-1392
  • Fax: 773-285-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036-36570
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: