Healthcare Provider Details

I. General information

NPI: 1144374752
Provider Name (Legal Business Name): THOMAS SMITH HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 W MAIN ST
DECATUR IL
62523-1215
US

IV. Provider business mailing address

252 W MAIN ST
DECATUR IL
62523-1215
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-6042
  • Fax:
Mailing address:
  • Phone: 217-422-6042
  • Fax: 217-233-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1950
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: