Provider Demographics
NPI:1568544997
Name:SMITH, KEVIN MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 5100
Mailing Address - Street 2:SUNNY ISLE
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00823-5100
Mailing Address - Country:US
Mailing Address - Phone:340-772-9557
Mailing Address - Fax:340-772-9558
Practice Address - Street 1:SUNNY ISLE PROFESSIONAL BUILDING
Practice Address - Street 2:SUITE 6F
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00823-5100
Practice Address - Country:US
Practice Address - Phone:340-772-9557
Practice Address - Fax:340-772-9558
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI78225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI5-6728 CMedicare ID - Type UnspecifiedMEDI INDIVIDUAL NUMBER