MEDICARE: SARGAM SHAH RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	05007841A	IN

General Provider Information

NPI Number	:	1295716942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARGAM SHAH RPT

Provider Business Mailing Address
First Line	:	2872 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1669
Country	:	US
Telephone Number	:	260-497-0838
Fax Number	:	260-497-9088

Provider Business Practice Location Address
First Line	:	2872 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1669
Country	:	US
Telephone Number	:	260-497-0838
Fax Number	:	260-497-9088

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	07/08/2007

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