Basic Information
| Provider Information | |||||||||
| NPI: | 1841267655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | PT, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 N 15TH ST | ||||||||
| Address2: | MS 502 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157621758 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191231957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157691100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT016957 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 1010724000002 | 05 | PA | MEDICAID |