Provider Demographics
NPI:1902079981
Name:SHAH, MIRAB MICKEY (PT)
Entity Type:Individual
Prefix:
First Name:MIRAB
Middle Name:MICKEY
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 1:16517 106TH CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4545
Mailing Address - Country:US
Mailing Address - Phone:708-966-4386
Mailing Address - Fax:708-966-4387
Practice Address - Street 1:7700 GRAPHIC DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6228
Practice Address - Country:US
Practice Address - Phone:708-308-7919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619908OtherBCBS IL GROUP
IL568080OtherMEDICARE GROUP NUMBER
IL567700OtherMEDICARE GROUP NUMBER
IL568150OtherMEDICARE GROUP NUMBER
ILR01012Medicare PIN
IL568150OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP