Healthcare Provider Details

I. General information

NPI: 1649694936
Provider Name (Legal Business Name): EMMETT SMITH JR.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18660 GRAPHIC DR SUITE 100
TINLEY PARK IL
60477-6260
US

IV. Provider business mailing address

18660 GRAPHIC DR SUITE 100
TINLEY PARK IL
60477-6260
US

V. Phone/Fax

Practice location:
  • Phone: 708-263-2000
  • Fax: 708-263-2024
Mailing address:
  • Phone: 708-263-2000
  • Fax: 708-263-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: