Healthcare Provider Details

I. General information

NPI: 1023495363
Provider Name (Legal Business Name): MATTHEW PHILIP SMITH MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COLLEGE AND MAIN CAPITAL ATHLETIC TRAINING
BEXLEY OH
43209-7812
US

IV. Provider business mailing address

1 COLLEGE AND MAIN CAPITAL ATHLETIC TRAINING
BEXLEY OH
43209-7812
US

V. Phone/Fax

Practice location:
  • Phone: 614-236-6622
  • Fax: 614-236-6624
Mailing address:
  • Phone: 614-236-6622
  • Fax: 614-236-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number4500
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1133
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: