Healthcare Provider Details

I. General information

NPI: 1003895731
Provider Name (Legal Business Name): BRADFORD LAWRENCE SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 6TH ST DEPARTMENT OF PEDIATRICS
GREAT LAKES IL
60088-2833
US

IV. Provider business mailing address

3001 6TH ST DEPARTMENT OF PEDIATRICS
GREAT LAKES IL
60088-2833
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2255
  • Fax:
Mailing address:
  • Phone: 847-688-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101102811
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: