Provider Demographics
NPI:1215025564
Name:SMOLKO, CHRISTOPHER JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:SMOLKO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-7522
Mailing Address - Country:US
Mailing Address - Phone:440-946-5858
Mailing Address - Fax:440-918-4870
Practice Address - Street 1:7230 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7522
Practice Address - Country:US
Practice Address - Phone:440-946-5858
Practice Address - Fax:440-918-4870
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH20-0715484OtherTAX IDENTIFICATION NUMBER
OH010069OtherSTATE OF OHIO LICENSE #
OHP91440Medicare UPIN
OH4108884Medicare ID - Type Unspecified