Provider Demographics
NPI:1306823802
Name:SMITH, PHILLIP T (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 N BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013
Mailing Address - Country:US
Mailing Address - Phone:513-805-4499
Mailing Address - Fax:513-805-4498
Practice Address - Street 1:1 N BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013
Practice Address - Country:US
Practice Address - Phone:513-805-4499
Practice Address - Fax:513-805-4499
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003797RX363A00000X
MSPA074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0090172Medicaid
MSQ54694Medicare UPIN