Basic Information
Provider Information | |||||||||
NPI: | 1649581059 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | MARK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | JAY | ||||||||
OtherMiddleName: | MARK | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 820 SPRINGER DR | ||||||||
Address2: |   | ||||||||
City: | LOMBARD | ||||||||
State: | IL | ||||||||
PostalCode: | 601486413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8157448554 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24 WHITE BRIDGE RD | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372051411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153520011 | ||||||||
FaxNumber: | 6153520085 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2010 | ||||||||
LastUpdateDate: | 04/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 50688 | TN | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 50688 | TN | N |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.