Basic Information
| Provider Information | |||||||||
| NPI: | 1306063219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 TRACY WAY | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043884965 | ||||||||
| FaxNumber: | 3043434850 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 MACCORKLE AVE SE | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043885120 | ||||||||
| FaxNumber: | 3043885125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 12/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 21092 | WV | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1808963000 | 05 | WV | MEDICAID |