Provider Demographics
NPI:1619064300
Name:SMITH, BRETT I
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:I
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 GRUNDMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:NEBRASKA CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68410-3397
Mailing Address - Country:US
Mailing Address - Phone:402-873-7411
Mailing Address - Fax:402-873-7413
Practice Address - Street 1:1104 GRUNDMAN BLVD
Practice Address - Street 2:
Practice Address - City:NEBRASKA CITY
Practice Address - State:NE
Practice Address - Zip Code:68410-3397
Practice Address - Country:US
Practice Address - Phone:402-873-7411
Practice Address - Fax:402-873-7413
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36520OtherBCBS
NE650016963OtherRR MEDICARE
NE272055Medicare ID - Type Unspecified