Healthcare Provider Details

I. General information

NPI: 1811522451
Provider Name (Legal Business Name): ALEXANDER JOSEPH SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ROTTINGHAM CT STE A
EDWARDSVILLE IL
62025-3677
US

IV. Provider business mailing address

5220 6TH STREET FRONTAGE RD E STE 1700
SPRINGFIELD IL
62703-5771
US

V. Phone/Fax

Practice location:
  • Phone: 866-522-2467
  • Fax:
Mailing address:
  • Phone: 217-525-8332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-39795
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: