MEDICARE: MR. LAWRENCE J SMITH M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	036-083903	IL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	390002195	OTHER		RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	336-046165	OTHER	IL	IL CONTROLLED SUBSTANCE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	036083903	OTHER		BLUE CROSS BLUE SHIELD
5	175974	OTHER		HEALTHLINK CIGNA
6	44761	OTHER		GHP

NPI Number	:	1457323669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LAWRENCE J SMITH M.D.

Provider Business Mailing Address
First Line	:	3401 CONIFER DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-8300
Country	:	US
Telephone Number	:	217-726-0967
Fax Number	:	217-726-7633

Provider Business Practice Location Address
First Line	:	3401 CONIFER DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-8300
Country	:	US
Telephone Number	:	217-726-0967
Fax Number	:	217-726-7633

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	03/07/2023

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039