Healthcare Provider Details

I. General information

NPI: 1649632993
Provider Name (Legal Business Name): KEVIN DONALD SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC1145
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-3020
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberC7-0007316
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberDR.0062439
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number036.164127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: