Provider Demographics
NPI:1386617249
Name:SMITH, LIONEL JOE (MD)
Entity type:Individual
Prefix:
First Name:LIONEL
Middle Name:JOE
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 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:1603 MORGAN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3430
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101588207Q00000X
IAMD-44053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101588Medicaid
IAIB1661006Medicare PIN
E58431Medicare UPIN
IL036101588Medicaid