Healthcare Provider Details

I. General information

NPI: 1124486360
Provider Name (Legal Business Name): NIRAD SHAH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13631 W 11 MILE RD
OAK PARK MI
48237-1151
US

IV. Provider business mailing address

260 COACHMAN DR APT 3D
TROY MI
48083-4728
US

V. Phone/Fax

Practice location:
  • Phone: 248-298-0433
  • Fax:
Mailing address:
  • Phone: 248-688-6295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501015186
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: