Provider Demographics
NPI:1326031105
Name:SMITH, GLEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:B
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7906
Mailing Address - Country:US
Mailing Address - Phone:309-662-5506
Mailing Address - Fax:309-662-5443
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7906
Practice Address - Country:US
Practice Address - Phone:309-662-5506
Practice Address - Fax:309-662-5443
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036075454208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL008131OtherHEALTH ALLIANCE PROVIDER
MO205477201Medicaid
37773OtherPHCS
37893OtherTRICARE
228074OtherHEALTHLINK
036075454000OtherOSF HEALTH PLANS
IL05732036OtherBLUE SHIELD GROUP NUMBER
233989OtherPERSONAL CARE
1955270OtherUNITED HEALTHCARE
IL0102OtherJOHN DEERE HEALTH PLAN
IL$$$$$$$$$Medicaid
233989OtherPERSONAL CARE
IL008131OtherHEALTH ALLIANCE PROVIDER
IL05732036OtherBLUE SHIELD GROUP NUMBER