Healthcare Provider Details

I. General information

NPI: 1861805673
Provider Name (Legal Business Name): CHRISTOPHER MICHAEL SMITH M.ED., ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 RIDGEWAY RD
MEMPHIS TN
38119-5314
US

IV. Provider business mailing address

1740 RIDGEWAY RD
MEMPHIS TN
38119-5314
US

V. Phone/Fax

Practice location:
  • Phone: 901-605-9550
  • Fax:
Mailing address:
  • Phone: 901-605-9550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0000001016
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: