Basic Information
| Provider Information | |||||||||
| NPI: | 1932118239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E. GRANT STREET | ||||||||
| Address2: | OUT PATIENT SERVICES SUITE | ||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098366937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 E. GRANT STREET | ||||||||
| Address2: | OUTPATIENT SERVICES SUITE | ||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098366937 | ||||||||
| FaxNumber: | 3098361547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 20A6984 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 036-126160 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00AX69840 | 05 | CA | MEDICAID |