Basic Information
| Provider Information | |||||||||
| NPI: | 1801131503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4058 | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CROFTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211144058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103159080 | ||||||||
| FaxNumber: | 4103159012 | ||||||||
| Practice Location | |||||||||
| Address1: | 2430 BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210932262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103083543 | ||||||||
| FaxNumber: | 4103084663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 24264 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.