Provider Demographics
NPI:1194891804
Name:SMITH, TROY L (MPT)
Entity type:Individual
Prefix:MR
First Name:TROY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:10876 ISABELLE DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2097
Practice Address - Country:US
Practice Address - Phone:260-748-2233
Practice Address - Fax:260-748-2277
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003926A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087959OtherANTHEM BCBS
IN4423623OtherAETNA
IN156546OtherMEDICARE
IN200363010AMedicaid
INN238029OtherHARMONY
IN1424OtherPHP
IN35179001202OtherCARESOURCE