Provider Demographics
NPI:1508837519
Name:SMITH, JEFFREY RYAN (MPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1940
Mailing Address - Fax:
Practice Address - Street 1:6059 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4453
Practice Address - Country:US
Practice Address - Phone:602-429-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02984225100000X
AZ12570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1213Medicare PIN
IAIB1213047Medicare PIN