Provider Demographics
NPI:1770574923
Name:SMITH, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:1805 LOUCKS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17404-7902
Mailing Address - Country:US
Mailing Address - Phone:717-764-0144
Mailing Address - Fax:717-764-0554
Practice Address - Street 1:1805 LOUCKS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17404-7902
Practice Address - Country:US
Practice Address - Phone:717-764-0144
Practice Address - Fax:717-764-0554
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT01591225100000X
NY0267602081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02630986Medicaid
NYRA5598Medicare ID - Type Unspecified
PA075144R9XMedicare ID - Type Unspecified