Basic Information
| Provider Information | |||||||||
| NPI: | 1114108123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | TAMI | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 102 | ||||||||
| Address2: | NOVANT MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772435 | ||||||||
| FaxNumber: | 3362779275 | ||||||||
| Practice Location | |||||||||
| Address1: | 485 VALLEY RD | ||||||||
| Address2: | MEDICAL ASSOCIATES OF DAVIE | ||||||||
| City: | MOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270282074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367518000 | ||||||||
| FaxNumber: | 3367518010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5754 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.