Provider Demographics
NPI:1982662060
Name:SMITH, GREGORY H (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:H
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:311 W. FAIRCHILD STREET
Practice Address - Street 2:FAMILY MEDICINE/CONVENIENT CARE
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-431-7650
Practice Address - Fax:217-431-7634
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064047207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064047Medicaid
IL6447860014Medicare NSC
ILIL3270470Medicare PIN
C43394Medicare UPIN
ILK06173Medicare PIN
IL036064047Medicaid