Basic Information
| Provider Information | |||||||||
| NPI: | 1164771614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DNP, ANP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SPRINGER DR | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086344602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 311 E 89TH AVE | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464108162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197697062 | ||||||||
| FaxNumber: | 6304951770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2012 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP 22695 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 71008935A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | APRN001802 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 28250476A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | RN 805484 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN9310400 | FL | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN80537 | NV | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | MCO300042636 | 05 | IN | MEDICAID |