Healthcare Provider Details

I. General information

NPI: 1902376239
Provider Name (Legal Business Name): ELIAS BOUSHEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 E MARYLAND ST
DECATUR IL
62521-9705
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-1264
  • Fax: 217-864-1828
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070027717
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: