Provider Demographics
NPI:1033137815
Name:SMITH, SETH E (MD)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-328-8080
Mailing Address - Fax:
Practice Address - Street 1:2424 S 90TH ST FL 3
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8080
Practice Address - Fax:414-328-8350
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41274208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033137815Medicaid
G28146Medicare UPIN
07125-0231Medicare ID - Type Unspecified