Healthcare Provider Details

I. General information

NPI: 1780918540
Provider Name (Legal Business Name): KRISTEN DIANE SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN DIANE MCCORD M.D.

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GLENWOOD AVE
JOLIET IL
60435-5487
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-2121
  • Fax:
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01096117A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01096117A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-055924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: