Basic Information
| Provider Information | |||||||||
| NPI: | 1629646013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIKANY | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 6625 W LINCOLN HWY # LL | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463079678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194405360 | ||||||||
| FaxNumber: | 2194405361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | 99104772A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 225200000X | 99104772A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.