Provider Demographics
NPI:1477944627
Name:SMITH, MICHAEL S (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 TAMIAMI TRL STE 704
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9283
Mailing Address - Country:US
Mailing Address - Phone:941-423-5600
Mailing Address - Fax:
Practice Address - Street 1:4161 TAMIAMI TRL STE 704
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9283
Practice Address - Country:US
Practice Address - Phone:941-423-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-4308734261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)