Provider Demographics
NPI:1386784346
Name:SMITH, CARROLL EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4900 S GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2816
Mailing Address - Country:US
Mailing Address - Phone:773-285-1392
Mailing Address - Fax:773-285-2779
Practice Address - Street 1:4215 S KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-2663
Practice Address - Country:US
Practice Address - Phone:773-624-0366
Practice Address - Fax:773-624-0367
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-36570207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-36570OtherSTATE LICENSE