Basic Information
Provider Information | |||||||||
NPI: | 1104837079 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RICHARD D. SHIN, M.D., S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1730 PARK ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605632688 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307180200 | ||||||||
FaxNumber: | 6307180900 | ||||||||
Practice Location | |||||||||
Address1: | 1225 W LAKE ST | ||||||||
Address2: |   | ||||||||
City: | MELROSE PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 601604039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7089387580 | ||||||||
FaxNumber: | 7089387381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 11/12/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHIN | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
AuthorizedOfficialTelephone: | 6307180200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0105X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand |
ID Information
ID | Type | State | Issuer | Description | 01622834 | 01 | IL | BLUE CROSS / BLUE SHIELD | OTHER |