Provider Demographics
NPI:1295908358
Name:BAJWA, SIKANDER M (MAOM, PT)
Entity type:Individual
Prefix:MR
First Name:SIKANDER
Middle Name:M
Last Name:BAJWA
Suffix:
Gender:M
Credentials:MAOM, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2046
Mailing Address - Country:US
Mailing Address - Phone:314-616-1276
Mailing Address - Fax:314-741-3801
Practice Address - Street 1:1519 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2046
Practice Address - Country:US
Practice Address - Phone:314-616-1276
Practice Address - Fax:314-741-3801
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011293251E00000X
MO830-HH251E00000X
MO2000174761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2714157826222601Medicaid
000015685Medicare PIN
14-8190Medicare PIN
26-7626Medicare PIN
219075685Medicare PIN