Provider Demographics
NPI:1972687747
Name:SMITH, TIY (MD)
Entity Type:Individual
Prefix:
First Name:TIY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2089
Mailing Address - Country:US
Mailing Address - Phone:312-337-1073
Mailing Address - Fax:312-337-7616
Practice Address - Street 1:1276 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2089
Practice Address - Country:US
Practice Address - Phone:312-337-1073
Practice Address - Fax:312-337-7616
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-102680208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
367830Medicare PIN
I49273Medicare UPIN