Provider Demographics
NPI:1922630607
Name:SMITH, IAN MICHAEL
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
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 1:110 ROCK BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63089-2006
Mailing Address - Country:US
Mailing Address - Phone:636-221-0091
Mailing Address - Fax:
Practice Address - Street 1:2275 SOMMERS RD
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-6406
Practice Address - Country:US
Practice Address - Phone:636-561-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170226952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer