Basic Information
| Provider Information | |||||||||
| NPI: | 1578503744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SIMA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JOLIET ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198643300 | ||||||||
| FaxNumber: | 2198642569 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 JOLIET ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198643300 | ||||||||
| FaxNumber: | 2198642569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05008167A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000306105 | 01 | IN | ANTHEM - APT PLUS | OTHER | 000000320909 | 01 | IN | ANTHEM - 1ST AID PLUS | OTHER | 000000324508 | 01 | IN | ANTHEM - MBWOUDE | OTHER | P00608812 | 01 | IL | RAILROAD GROUP MEMBER PTAN | OTHER |