Provider Demographics
NPI:1588626733
Name:SMOLEN-HETZEL, JOHN M (DPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:SMOLEN-HETZEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6563 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4051
Mailing Address - Country:US
Mailing Address - Phone:269-488-3320
Mailing Address - Fax:269-372-6113
Practice Address - Street 1:6563 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-4051
Practice Address - Country:US
Practice Address - Phone:269-488-3320
Practice Address - Fax:269-372-6113
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8405225100000X
WI225100000X
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI830420046Medicare PIN
WI832070026Medicare PIN