Provider Demographics
NPI:1518299536
Name:SHAH, MITI G (DPT)
Entity Type:Individual
Prefix:
First Name:MITI
Middle Name:G
Last Name:SHAH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MITI
Other - Middle Name:S
Other - Last Name:GANDHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:7511 LEMONT RD
Practice Address - Street 2:SUITE 204
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-4394
Practice Address - Country:US
Practice Address - Phone:630-985-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00855677OtherMEDICARE RR
ILP00865624OtherMEDICARE RR
IL202845082Medicare PIN
IL214692018Medicare PIN
IL211585030Medicare PIN
ILP00865624OtherMEDICARE RR
IL216859047Medicare PIN