Provider Demographics
NPI:1710096557
Name:SMITH, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 BURR RIDGE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0833
Mailing Address - Country:US
Mailing Address - Phone:630-756-5270
Mailing Address - Fax:
Practice Address - Street 1:1333 BURR RIDGE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0833
Practice Address - Country:US
Practice Address - Phone:630-756-5270
Practice Address - Fax:574-538-4859
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093367Medicaid
ILL74826Medicare ID - Type Unspecified
ILL54066Medicare ID - Type Unspecified
G27771Medicare UPIN