Provider Demographics
NPI:1194834937
Name:SMITH, JIMMIE MARQUETTE (MD)
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:MARQUETTE
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 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5101
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1942315197OtherNPI CLINIC NUMBER
ILCG5172OtherRR MEDICARE GROUP#
IL014146OtherHEALTH ALLIANCE
IL110200800OtherRR MEDICARE PIN
ILIL0112OtherJOHN DEERE
IL0062839OtherUMWA
IL02922981OtherBCBS
IL036085766Medicaid
IL085766OtherOSF HEALTHPLANS
IL200397OtherBLACK LUNG
IL207537OtherHEALTH LINK
ILL71192Medicare PIN
IL0062839OtherUMWA
IL036085766Medicaid