=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700464526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEC SAMUEL SMALL DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2021
-----------------------------------------------------
Last Update Date | 09/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10400 75TH ST
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53142-7884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-948-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 808 S WOOD ST RM 469A
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 036.166609
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 81508-21
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------