Provider Demographics
NPI:1134340227
Name:ROGERS SMITH, THERESA A (PAC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:ROGERS SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:ROGERS HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-9257
Practice Address - Street 1:4241 STATE HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-1037
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:618-724-4628
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002815363A00000X
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00428388Medicare PIN
DE7181Medicare PIN
IL213567Medicare PIN
ILK39412Medicare UPIN