MEDICARE: DR. KYLA NICHELLE SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	036-128969	IL
2	208000000X	Pediatrics Physician	036-128969	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316075559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLA NICHELLE SMITH M.D.

Provider Business Mailing Address
First Line	:	2001 S CALIFORNIA AVE STE 100
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2486
Country	:	US
Telephone Number	:	773-584-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3059 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623
Country	:	US
Telephone Number	:	773-584-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	09/29/2020

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