Basic Information
| Provider Information | |||||||||
| NPI: | 1629556303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | REPT, CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8118 CORPORATE WAY STE 212 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450409560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139478433 | ||||||||
| FaxNumber: | 5139479943 | ||||||||
| Practice Location | |||||||||
| Address1: | 8118 CORPORATE WAY STE 212 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450409560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139478433 | ||||||||
| FaxNumber: | 5139479943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.