Provider Demographics
NPI:1063437150
Name:SMITH, BRUCE SYLVESTER (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:SYLVESTER
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W 6TH ST
Mailing Address - Street 2:STE 206
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2899
Mailing Address - Country:US
Mailing Address - Phone:815-672-1610
Mailing Address - Fax:815-672-1615
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:STE 206
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2899
Practice Address - Country:US
Practice Address - Phone:815-672-1610
Practice Address - Fax:815-672-1615
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36093924207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36093924Medicaid
G84960Medicare UPIN
213399Medicare ID - Type Unspecified