Provider Demographics
NPI:1285186742
Name:SMITH, MARIE JUDE
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:JUDE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14411 S EGGLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2671
Mailing Address - Country:US
Mailing Address - Phone:708-265-1636
Mailing Address - Fax:708-893-0550
Practice Address - Street 1:14411 S EGGLESTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2671
Practice Address - Country:US
Practice Address - Phone:708-265-1636
Practice Address - Fax:708-893-0550
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS53055073961343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)