Provider Demographics
NPI:1467487975
Name:SMYK, ROMAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:M
Last Name:SMYK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:35 E WILLOW ST STE B
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1869
Mailing Address - Country:US
Mailing Address - Phone:815-634-3048
Mailing Address - Fax:815-634-8188
Practice Address - Street 1:460 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1045
Practice Address - Country:US
Practice Address - Phone:815-634-2592
Practice Address - Fax:815-634-4052
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03606684Medicaid
IL040002092OtherRAILROAD MEDICARE
IL3200048OtherBLUE CROSS BLUE SHIELD
IL770420Medicare ID - Type Unspecified
IL03606684Medicaid