Provider Demographics
NPI:1689738684
Name:SHIDI, SHAMSAH (PT)
Entity Type:Individual
Prefix:MISS
First Name:SHAMSAH
Middle Name:
Last Name:SHIDI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 DRUID RD. E
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3919
Mailing Address - Country:US
Mailing Address - Phone:727-447-8884
Mailing Address - Fax:727-447-0919
Practice Address - Street 1:611 DRUID RD. E
Practice Address - Street 2:SUITE 301
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3919
Practice Address - Country:US
Practice Address - Phone:727-447-8884
Practice Address - Fax:727-447-0919
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 5859225100000X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882775300Medicaid
FLPT5859OtherPHYSICAL THERAPY LICENSE
FL882775300Medicaid
FL593410580OtherEIN OR TAX ID NUMBER
FL106986Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
FL1720144470Medicare PIN