Provider Demographics
NPI:1902079981
Name:SHAH, MIRAB MICKEY (PT)
Entity type:Individual
Prefix:DR
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 1:16517 106TH CT
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-4545
Practice Address - Country:US
Practice Address - Phone:708-966-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060010072261QP2000X
IL070013727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL568080OtherMEDICARE GROUP NUMBER
IL568150OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP
IL567700OtherMEDICARE GROUP NUMBER
ILR01012Medicare PIN
IL568150OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP