Provider Demographics
NPI:1215058490
Name:THOMPSON, GWYNETH SMITH (MD)
Entity type:Individual
Prefix:MS
First Name:GWYNETH
Middle Name:SMITH
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWYNETH
Other - Middle Name:ALEXANDRA
Other - Last Name:SMITH
Other - Suffix:V
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-7578
Mailing Address - Fax:217-545-1884
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 6W100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-5117
Practice Address - Fax:217-545-7958
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113866207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113866Medicaid
ILK52821Medicare PIN