Provider Demographics
NPI:1962687020
Name:SHAH, PRIMITKUMAR P (PT)
Entity Type:Individual
Prefix:
First Name:PRIMITKUMAR
Middle Name:P
Last Name:SHAH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 INDIAN TRAIL ROAD
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2777
Mailing Address - Country:US
Mailing Address - Phone:630-621-2826
Mailing Address - Fax:708-683-5124
Practice Address - Street 1:106 INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2777
Practice Address - Country:US
Practice Address - Phone:630-621-2826
Practice Address - Fax:708-683-5124
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL557180Medicare PIN
ILL92391Medicare PIN