Basic Information
| Provider Information | |||||||||
| NPI: | 1124090329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | IN SOOK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 COMMUNITY DRIVE | ||||||||
| Address2: | ASPIRE OF WNY, INC. | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165055634 | ||||||||
| FaxNumber: | 7168921936 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 COMMUNITY DRIVE | ||||||||
| Address2: | ASPIRE OF WNY, INC. | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165055634 | ||||||||
| FaxNumber: | 7168921936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 04/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 134927-1 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00474924 | 05 | NY | MEDICAID |