Healthcare Provider Details

I. General information

NPI: 1851306153
Provider Name (Legal Business Name): TYLER J SMITH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ICEHOUSE RD
MEDFIELD MA
02052-1555
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 508-242-9478
  • Fax: 508-242-9489
Mailing address:
  • Phone: 630-296-2222
  • Fax: 630-759-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0400003612
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11612
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: