Provider Demographics
NPI:1174703177
Name:SMITH PHYSICAL THERAPY AND SPORTS MEDICINE
Entity type:Organization
Organization Name:SMITH PHYSICAL THERAPY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT/DPT/ATC
Authorized Official - Phone:989-390-1825
Mailing Address - Street 1:7516 COUNTRY PRIDE LN
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-9530
Mailing Address - Country:US
Mailing Address - Phone:989-390-1825
Mailing Address - Fax:
Practice Address - Street 1:7516 COUNTRY PRIDE LN
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-9530
Practice Address - Country:US
Practice Address - Phone:989-390-1825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty