Healthcare Provider Details

I. General information

NPI: 1386831485
Provider Name (Legal Business Name): PHILLIP JOSEPH SMITH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 11/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N KEENE ST STE 102
COLUMBIA MO
65201-7193
US

IV. Provider business mailing address

303 N KEENE ST STE102
COLUMBIA MO
65201-7193
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-0225
  • Fax: 573-443-0250
Mailing address:
  • Phone: 573-443-0225
  • Fax: 573-443-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2001024950
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: