=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841775244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAHID KHAN OTR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2018
-----------------------------------------------------
Last Update Date | 03/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 481 VILLAGE GREEN LN
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-3367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-242-6282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22109 NIXON AVE
-----------------------------------------------------
City | BROWNSTOWN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-8233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-846-6003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5201004246
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------