Healthcare Provider Details

I. General information

NPI: 1861491599
Provider Name (Legal Business Name): MICHAEL J SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST EMERGENCY MED.
URBANA IL
61801-2529
US

IV. Provider business mailing address

611 W PARK ST BWPC
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3313
  • Fax: 217-383-4014
Mailing address:
  • Phone: 217-383-6941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01063120
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036141508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: