MEDICARE: MR. BILLY G SMITH

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	224Z00000X	Occupational Therapy Assistant	208829	IL

General Provider Information

NPI Number	:	1184873317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BILLY G SMITH

Provider Business Mailing Address
First Line	:	415 GARDEN HEIGHT RD.
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946
Country	:	US
Telephone Number	:	618-841-2229
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 GARDEN HEIGHTS RD
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946-5202
Country	:	US
Telephone Number	:	618-841-2229
Fax Number	:

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

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	09/11/2008

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