Provider Demographics
NPI:1649694936
Name:SMITH, EMMETT JR
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18660 GRAPHIC DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6260
Mailing Address - Country:US
Mailing Address - Phone:708-263-2000
Mailing Address - Fax:708-263-2024
Practice Address - Street 1:18660 GRAPHIC DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6260
Practice Address - Country:US
Practice Address - Phone:708-263-2000
Practice Address - Fax:708-263-2024
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238000399OtherSURGICAL ASSISTANT