Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | IL |
NPI | 1194886366 |
---|---|
Provider Name | Dr. Robert G. Smith |
First Address | East Moline, IL 61244-4023 |
Second Address | East Moline, IL 61244-4023 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 08/07/2007 |