Provider Demographics
NPI:1346507811
Name:PERUMBULLY, SHIBU PORINCHU (PTA)
Entity Type:Individual
Prefix:
First Name:SHIBU
Middle Name:PORINCHU
Last Name:PERUMBULLY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 S KARLOV AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3388
Mailing Address - Country:US
Mailing Address - Phone:708-422-1461
Mailing Address - Fax:
Practice Address - Street 1:9725 S KARLOV AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3388
Practice Address - Country:US
Practice Address - Phone:708-422-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005937225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant