Basic Information
| Provider Information | |||||||||
| NPI: | 1346200938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712200 | ||||||||
| FaxNumber: | 8159719097 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712200 | ||||||||
| FaxNumber: | 8159719097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036078927 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0001X | 036078927 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | 036-078927 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036078927 | 05 | IL | MEDICAID | 1346200938 | 05 | WI | MEDICAID |