Provider Demographics
NPI:1144396409
Name:SMITH, JERRY ARTHUR (PT ATC L)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ARTHUR
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT ATC L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4850 W CENTURY PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254
Mailing Address - Country:US
Mailing Address - Phone:317-216-2828
Mailing Address - Fax:317-216-2839
Practice Address - Street 1:5603 W RAYMOND ST
Practice Address - Street 2:SUITE D REHAB
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241
Practice Address - Country:US
Practice Address - Phone:317-248-7964
Practice Address - Fax:317-248-5006
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001219A225100000X
IN36000196A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer