Provider Demographics
NPI:1043312911
Name:SMITH, BRADLEY A (MSPT,SCS,ATC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSPT,SCS,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WESLEY CIR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-9077
Mailing Address - Country:US
Mailing Address - Phone:317-679-2809
Mailing Address - Fax:317-877-0320
Practice Address - Street 1:117 WESLEY CIR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-9077
Practice Address - Country:US
Practice Address - Phone:317-679-2809
Practice Address - Fax:317-877-0320
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001715A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000502221OtherANTHEM BCBS PROVIDER NUMB
GADB9030OtherRAILROAD MEDICARE GROUP
GAP00479059OtherRAILROAD PTAN
IN215630EMedicare PIN