Healthcare Provider Details

I. General information

NPI: 1790997708
Provider Name (Legal Business Name): EDWARD HUNTINGTON SMITH JR. M.A., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 W 56TH STREET
INDIANAPOLIS IN
46254
US

IV. Provider business mailing address

3417 TIMBERBROOK CT.
DANVILLE IN
46122
US

V. Phone/Fax

Practice location:
  • Phone: 317-808-5208
  • Fax: 317-297-8086
Mailing address:
  • Phone: 317-892-3630
  • Fax: 317-297-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000056A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: