Provider Demographics
NPI:1801850615
Name:SMITH, JON R (ATC)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:R
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 1:162 BEVIER ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1015
Mailing Address - Country:US
Mailing Address - Phone:607-727-2498
Mailing Address - Fax:
Practice Address - Street 1:907 UPPER FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1328
Practice Address - Country:US
Practice Address - Phone:607-778-5050
Practice Address - Fax:607-778-5370
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000061-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer