Provider Demographics
NPI:1295183515
Name:SMITH, STEVEN
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 RIDGEMOOR DR
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2929
Practice Address - Country:US
Practice Address - Phone:618-466-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist