Provider Demographics
NPI:1841794674
Name:SMITH, TYLER PAUL
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:PAUL
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 1:2760 S HIGHLAND AVE APT 414
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 N YORK ST STE 300
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2784
Practice Address - Country:US
Practice Address - Phone:630-279-4852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.023550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist