=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902376239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIAS BOUSHEH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2018
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5255 E MARYLAND ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-9705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-864-1264
-----------------------------------------------------
Fax | 217-864-1828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1311 MAMARONECK AVE STE 140
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10605-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-294-4050
-----------------------------------------------------
Fax | 631-760-8306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070027717
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------