Provider Demographics
NPI:1649627076
Name:SHAH, KHUSHBOO R
Entity type:Individual
Prefix:
First Name:KHUSHBOO
Middle Name:R
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:2510 S TELEGRAPH RD STE I&J
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0241
Practice Address - Country:US
Practice Address - Phone:248-335-2000
Practice Address - Fax:248-335-2002
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist