Provider Demographics
NPI:1790436277
Name:SMITH, CORAN
Entity Type:Individual
Prefix:
First Name:CORAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S MAIN ST STE 700
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5635
Mailing Address - Country:US
Mailing Address - Phone:773-812-5675
Mailing Address - Fax:
Practice Address - Street 1:517 W 103RD PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-2407
Practice Address - Country:US
Practice Address - Phone:773-812-5675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS53010478239172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver