Provider Demographics
NPI:1972513505
Name:SHADDIX, MISHA M (RPT)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:M
Last Name:SHADDIX
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7088 UNIVERSITY CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6992
Mailing Address - Country:US
Mailing Address - Phone:334-396-1400
Mailing Address - Fax:334-396-2727
Practice Address - Street 1:7088 UNIVERSITY CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-6992
Practice Address - Country:US
Practice Address - Phone:334-396-1400
Practice Address - Fax:334-396-2727
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH 4337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00172017OtherRAILROAD MEDICARE #
ALQ24656Medicare UPIN