MEDICARE: HETAL A SHAH LPT

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	225100000X	Physical Therapist		IL

General Provider Information

NPI Number	:	1336168269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HETAL A SHAH LPT

Provider Business Mailing Address
First Line	:	5220 S 6TH STREET RD
Second Line	:	SUITE 1500
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-5735
Country	:	US
Telephone Number	:	217-529-8469
Fax Number	:	217-529-5580

Provider Business Practice Location Address
First Line	:	5220 S 6TH STREET RD
Second Line	:	SUITE 1500
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-5735
Country	:	US
Telephone Number	:	217-529-8469
Fax Number	:	217-529-5580

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	12/12/2007

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