Provider Demographics
NPI:1386831485
Name:SMITH, PHILLIP JOSEPH (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:303 N KEENE ST
Mailing Address - Street 2:STE102
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7193
Mailing Address - Country:US
Mailing Address - Phone:573-443-0225
Mailing Address - Fax:573-443-0250
Practice Address - Street 1:303 N KEENE ST
Practice Address - Street 2:STE 102
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7193
Practice Address - Country:US
Practice Address - Phone:573-443-0225
Practice Address - Fax:573-443-0250
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2001024950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO217494243Medicare PIN