Provider Demographics
NPI:1932118239
Name:SMITH, TAMARA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E. GRANT STREET
Mailing Address - Street 2:OUT PATIENT SERVICES SUITE
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455
Mailing Address - Country:US
Mailing Address - Phone:309-836-6937
Mailing Address - Fax:
Practice Address - Street 1:525 E. GRANT STREET
Practice Address - Street 2:OUTPATIENT SERVICES SUITE
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:309-836-6937
Practice Address - Fax:309-836-6530
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6984207V00000X
IL036-126160207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX69840Medicaid
CA00AX69840Medicaid
G64686Medicare UPIN