Provider Demographics
NPI:1568916583
Name:SMITH, KELSEY H (P)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:H
Last Name:SMITH
Suffix:
Gender:F
Credentials:P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 W CENTRAL RD
Mailing Address - Street 2:DEPARTMENT OF NEUROSURGERY
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2355
Mailing Address - Country:US
Mailing Address - Phone:847-570-1440
Mailing Address - Fax:847-570-1442
Practice Address - Street 1:880 W CENTRAL RD DEPT OF
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2355
Practice Address - Country:US
Practice Address - Phone:847-570-1440
Practice Address - Fax:847-570-1442
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3881363A00000X
WI3881-23363AS0400X
IL085008913363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100060159Medicaid