Provider Demographics
NPI:1275632689
Name:SMITH, ED R (PT)
Entity Type:Individual
Prefix:MR
First Name:ED
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:6169 JOG ROAD
Mailing Address - Street 2:SUITE A11
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467
Mailing Address - Country:US
Mailing Address - Phone:561-432-0111
Mailing Address - Fax:561-432-1075
Practice Address - Street 1:11120 S CROWN WAY
Practice Address - Street 2:SUITE B
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-656-1028
Practice Address - Fax:561-656-1031
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPT4846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL819453OtherACN GROUP
FLU3654ZMedicare ID - Type Unspecified