Provider Demographics
NPI:1588607345
Name:RUDYARD SMITH MD AND ASSOCIATES SC
Entity Type:Organization
Organization Name:RUDYARD SMITH MD AND ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUDYARD
Authorized Official - Middle Name:U
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:773-978-0757
Mailing Address - Street 1:7906 S CRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1146
Mailing Address - Country:US
Mailing Address - Phone:773-978-0757
Mailing Address - Fax:773-978-0705
Practice Address - Street 1:1514 E 87TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6525
Practice Address - Country:US
Practice Address - Phone:773-978-0757
Practice Address - Fax:773-978-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053241207R00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053241001Medicaid
IL110233216OtherRAILROAD MEDICARE