Healthcare Provider Details

I. General information

NPI: 1821766973
Provider Name (Legal Business Name): GARRETT WILLIAM SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 EAST OUTER DR
MARION IL
62959-5207
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-3817
  • Fax: 618-993-3908
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30314
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209024498
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: