Provider Demographics
NPI:1477600534
Name:SMAHA, KIM A (PT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:SMAHA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1854 FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1169
Mailing Address - Country:US
Mailing Address - Phone:478-755-1157
Mailing Address - Fax:478-755-1158
Practice Address - Street 1:1854 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1169
Practice Address - Country:US
Practice Address - Phone:478-755-1157
Practice Address - Fax:478-755-1158
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52676664-001OtherBLUE CROSS BLUE SHIELD
GA52676664-001OtherBLUE CROSS BLUE SHIELD
GA65BBBLPMedicare ID - Type Unspecified