Healthcare Provider Details

I. General information

NPI: 1417945122
Provider Name (Legal Business Name): WALTER K SMITH MED, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 17TH ST ASSEMBLY HALL
BLOOMINGTON IN
47408-1590
US

IV. Provider business mailing address

6416 E COX DR
BLOOMINGTON IN
47408-9517
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-3621
  • Fax: 812-855-1810
Mailing address:
  • Phone: 812-336-2661
  • Fax: 812-855-1810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000057A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: