Provider Demographics
NPI:1215048079
Name:SMITH, ERIS W (PT)
Entity type:Individual
Prefix:
First Name:ERIS
Middle Name:W
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 19TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1649
Mailing Address - Country:US
Mailing Address - Phone:701-839-4102
Mailing Address - Fax:
Practice Address - Street 1:1600 2ND AVE SW
Practice Address - Street 2:SUITE 24
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3459
Practice Address - Country:US
Practice Address - Phone:701-839-4102
Practice Address - Fax:701-838-9603
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20742OtherBLUE CROSS/BLUE SHIELD
ND52828Medicaid
NDP00296963001OtherRAILROAD MEDICARE
ND450461512000OtherWORKFORCE SAFETY INSURANC
ND52828Medicaid