Provider Demographics
NPI:1497045579
Name:SMITH, MARC GERALD (IDC)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:GERALD
Last Name:SMITH
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3355 ILLINOIS ST
Mailing Address - Street 2:BLDG 1405
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-3115
Mailing Address - Country:US
Mailing Address - Phone:847-688-4346
Mailing Address - Fax:847-688-3690
Practice Address - Street 1:3355 ILLINOIS ST
Practice Address - Street 2:BLDG 1007
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-3115
Practice Address - Country:US
Practice Address - Phone:847-688-4346
Practice Address - Fax:847-688-3690
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman