Basic Information
| Provider Information | |||||||||
| NPI: | 1043327141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1105 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185290568 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 RUSHING DRIVE | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189433300 | ||||||||
| FaxNumber: | 6189976626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036067104 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10019630 | 01 | BLUE CROSS/BLUE SHIELD | OTHER | 115574 | 01 | HEALTHLINK | OTHER | 036067104 | 05 | IL | MEDICAID | 033352 | 01 | HEALTH ALLIANCE | OTHER | 080075455 | 01 | RAILROAD MEDICARE | OTHER | 143870 | 05 | IL | MEDICAID |