Provider Demographics
NPI:1023825072
Name:SMITH, ALEXANDER JOHN (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOHN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 BALL DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:IN
Mailing Address - Zip Code:47243-9648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 BALL DR
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IN
Practice Address - Zip Code:47243-9648
Practice Address - Country:US
Practice Address - Phone:224-256-3025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT22062255A2300X
IN36003781A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer