MEDICARE: DR. CARROLL EDWARD 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	207QA0505X	Adult Medicine Physician	036-36570	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036-36570	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1386784346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARROLL EDWARD SMITH M.D.

Provider Business Mailing Address
First Line	:	4900 S GREENWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-2816
Country	:	US
Telephone Number	:	773-285-1392
Fax Number	:	773-285-2779

Provider Business Practice Location Address
First Line	:	4215 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-2663
Country	:	US
Telephone Number	:	773-624-0366
Fax Number	:	773-624-0367

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	12/21/2025

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