Healthcare Provider Details

I. General information

NPI: 1295784031
Provider Name (Legal Business Name): RUDYARD URIAH SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 E 87TH ST
CHICAGO IL
60619-6525
US

IV. Provider business mailing address

539 SAINT ANDREWS DR
SCHERERVILLE IN
46375-2951
US

V. Phone/Fax

Practice location:
  • Phone: 773-978-0757
  • Fax: 773-978-0705
Mailing address:
  • Phone: 219-937-9653
  • Fax: 219-937-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number202250
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036053241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: