Basic Information
| Provider Information | |||||||||
| NPI: | 1689886202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4140 SOUTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | HOMETOWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604561135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084225700 | ||||||||
| FaxNumber: | 7084229535 | ||||||||
| Practice Location | |||||||||
| Address1: | 9555 S 52ND AVE STE F | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604533054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084225700 | ||||||||
| FaxNumber: | 7084228225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036117083 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036117083 | 05 | IL | MEDICAID |