Provider Demographics
NPI:1134130859
Name:SMITH, CHAD RYAN (PT)
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:RYAN
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 1:9 MONTAUK HWY
Mailing Address - Street 2:UNIT A
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1136
Mailing Address - Country:US
Mailing Address - Phone:631-585-5915
Mailing Address - Fax:631-585-5916
Practice Address - Street 1:9 MONTAUK HWY
Practice Address - Street 2:UNIT A
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1136
Practice Address - Country:US
Practice Address - Phone:631-585-5915
Practice Address - Fax:631-585-5916
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQL6511Medicare ID - Type Unspecified