Provider Demographics
NPI:1225072697
Name:KEVIN D SMITH D P M P C
Entity Type:Organization
Organization Name:KEVIN D SMITH D P M P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-762-7919
Mailing Address - Street 1:505 VALLEY VIEW DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-762-7919
Mailing Address - Fax:309-517-6483
Practice Address - Street 1:505 VALLEY VIEW DR STE 1
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-762-7919
Practice Address - Fax:309-517-6483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004863213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG4825Medicare PIN
ILU79400Medicare UPIN
IL205375Medicare PIN
IL4761180001Medicare NSC