MEDICARE: STACEY ROBYN SMALLWOOD PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT4873	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3156797	OTHER	TN	BCBS GROUP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134342850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY ROBYN SMALLWOOD PT

Provider Business Mailing Address
First Line	:	9360 ROYAL MOUNTAIN DR
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-2067
Country	:	US
Telephone Number	:	423-316-5336
Fax Number	:

Provider Business Practice Location Address
First Line	:	9360 ROYAL MOUNTAIN DR
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-2067
Country	:	US
Telephone Number	:	423-316-5336
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	01/28/2016

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