Healthcare Provider Details

I. General information

NPI: 1710312012
Provider Name (Legal Business Name): IMELDA SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-9800
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax: 510-879-9084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-004814
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: