Healthcare Provider Details

I. General information

NPI: 1285620617
Provider Name (Legal Business Name): MICHAEL C SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST 1106
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1653 W CONGRESS PKWY 348 MURDOCK
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-4500
  • Fax: 312-942-2380
Mailing address:
  • Phone: 312-942-5939
  • Fax: 312-942-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036073603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: