Basic Information
| Provider Information | |||||||||
| NPI: | 1659674240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHANI | ||||||||
| MiddleName: | KAMARIA | ||||||||
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| Credential: | D.O., M.B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35318 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606781353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 203RD ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087096295 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2010 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036.130820 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RC0200X | 036.130820 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 036.130820 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | F00280905 | 01 | IL | MEDICARE IL PTAN | OTHER |