Provider Demographics
NPI:1336564780
Name:SMITH, HERBERT
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22525 ARQUILLA DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1533
Mailing Address - Country:US
Mailing Address - Phone:708-595-0237
Mailing Address - Fax:
Practice Address - Street 1:2532 W WARREN BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2124
Practice Address - Country:US
Practice Address - Phone:773-574-6092
Practice Address - Fax:773-785-2090
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343800000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)