Provider Demographics
NPI:1043327141
Name:SMITH, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
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 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-529-0568
Practice Address - Street 1:405 RUSHING DRIVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-943-3300
Practice Address - Fax:618-997-6626
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10019630OtherBLUE CROSS/BLUE SHIELD
115574OtherHEALTHLINK
IL036067104Medicaid
033352OtherHEALTH ALLIANCE
080075455OtherRAILROAD MEDICARE
IL143870Medicaid
IL143870Medicaid
IL036067104Medicaid
IL214881Medicare Oscar/Certification