Provider Demographics
NPI:1144958489
Name:SMITH, MAURICE ERICK
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:ERICK
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11005 S MICHIGAN AVE STE 427
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4308
Mailing Address - Country:US
Mailing Address - Phone:773-453-8883
Mailing Address - Fax:
Practice Address - Street 1:9839 SOUTH CHARLES STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1205
Practice Address - Country:US
Practice Address - Phone:773-750-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS53054568009172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver