Healthcare Provider Details

I. General information

NPI: 1467487975
Provider Name (Legal Business Name): ROMAN M SMYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N BROADWAY ST
COAL CITY IL
60416-1045
US

IV. Provider business mailing address

35 E WILLOW ST STE B
COAL CITY IL
60416-1869
US

V. Phone/Fax

Practice location:
  • Phone: 815-634-2592
  • Fax: 815-634-4052
Mailing address:
  • Phone: 815-634-3048
  • Fax: 815-634-8188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036066804
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: