Provider Demographics
NPI:1295784031
Name:SMITH, RUDYARD URIAH (MD)
Entity type:Individual
Prefix:DR
First Name:RUDYARD
Middle Name:URIAH
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 1:539 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2951
Mailing Address - Country:US
Mailing Address - Phone:219-937-9653
Mailing Address - Fax:219-937-1486
Practice Address - Street 1:1514 E 87TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6525
Practice Address - Country:US
Practice Address - Phone:773-978-0757
Practice Address - Fax:773-978-0705
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN202250207R00000X
IL036053241207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200414450AMedicaid
IL21627739OtherBLUE CROSS ID
IL036053241OtherLICENSE NUMBER
IN01037640AOtherLICENSE NUMBER
IL036053241001Medicaid
IL036053241001Medicaid