Provider Demographics
NPI:1215178314
Name:SMITH, MIKE R (LPT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SCHUYLKILL MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3668
Mailing Address - Country:US
Mailing Address - Phone:570-621-9500
Mailing Address - Fax:570-621-9510
Practice Address - Street 1:300 SCHUYLKILL MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3668
Practice Address - Country:US
Practice Address - Phone:570-621-9500
Practice Address - Fax:570-621-9510
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013630L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist