Provider Demographics
NPI:1639467590
Name:SHAH, RIDDHISH ASHOKKUMAR (RPT)
Entity Type:Individual
Prefix:
First Name:RIDDHISH
Middle Name:ASHOKKUMAR
Last Name:SHAH
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 ALEXANDER DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2602
Mailing Address - Country:US
Mailing Address - Phone:248-554-7098
Mailing Address - Fax:
Practice Address - Street 1:1961 ALEXANDER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2602
Practice Address - Country:US
Practice Address - Phone:248-554-7098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501015009OtherSTATE OF MI