MEDICARE: ELIAS BOUSHEH

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	2255A2300X	Athletic Trainer
2	225100000X	Physical Therapist	070027717	IL

General Provider Information

NPI Number	:	1902376239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIAS BOUSHEH

Provider Business Mailing Address
First Line	:	1311 MAMARONECK AVE STE 140
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-5224
Country	:	US
Telephone Number	:	914-294-4050
Fax Number	:	631-760-8306

Provider Business Practice Location Address
First Line	:	5255 E MARYLAND ST
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521-9705
Country	:	US
Telephone Number	:	217-864-1264
Fax Number	:	217-864-1828

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

Provider Enumeration Date	:	11/29/2018
Last Update Date	:	09/15/2023

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Directions to “ ELIAS BOUSHEH ” Practice Location

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