Provider Demographics
NPI:1851306153
Name:SMITH, TYLER J (PT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:2 ICEHOUSE RD
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-1555
Practice Address - Country:US
Practice Address - Phone:508-242-9478
Practice Address - Fax:508-242-9489
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003612225100000X
MA11612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010909Medicaid
00068268OtherBLUE CROSS BLUE SHIELD OF
7277652OtherAETNA
782961OtherMVP
VT1010909Medicaid