Provider Demographics
NPI:1396893160
Name:SMITH, GORDON E (LPT)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:117 BO BO DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2741
Practice Address - Country:US
Practice Address - Phone:601-892-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08276334Medicaid
LA1431281Medicaid