Provider Demographics
NPI:1619953973
Name:SMITH, SHAD JEFFRY (ATC)
Entity Type:Individual
Prefix:MR
First Name:SHAD
Middle Name:JEFFRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 N CAMPBELL RD
Mailing Address - Street 2:APT. 4
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1533
Mailing Address - Country:US
Mailing Address - Phone:941-527-7301
Mailing Address - Fax:
Practice Address - Street 1:1080 N CAMPBELL RD
Practice Address - Street 2:APT 4
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1533
Practice Address - Country:US
Practice Address - Phone:941-527-7301
Practice Address - Fax:313-577-1012
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer