Basic Information
| Provider Information | |||||||||
| NPI: | 1447645320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | JIMIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8054 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008629980 | ||||||||
| FaxNumber: | 3143621185 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N BALLAS RD | ||||||||
| Address2: | DIV ANES PAIN MGT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967200 | ||||||||
| FaxNumber: | 3143621185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2020020208 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 2020020208 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200089567 | 05 | MO | MEDICAID |