Basic Information
| Provider Information | |||||||||
| NPI: | 1033199187 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHIM | ||||||||
| FirstName: | SEONG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436241120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192518983 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1510 S CONWELL AVE | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448909448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199645700 | ||||||||
| FaxNumber: | 4199337822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35.067573 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 171406 | 05 | OH | MEDICAID |