Basic Information
| Provider Information | |||||||||
| NPI: | 1457541278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIMKO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1342 S DIVISION ST | ||||||||
| Address2: | #401 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218046921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105462133 | ||||||||
| FaxNumber: | 4105483361 | ||||||||
| Practice Location | |||||||||
| Address1: | 1342 S DIVISION ST | ||||||||
| Address2: | #401 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218046921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105462133 | ||||||||
| FaxNumber: | 4105483361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | 50973 | MN | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | D0073462 | MD | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | C1-0009994 | DE | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | P00645889 | 01 | MN | MEDICARE, RAILROAD | OTHER | ENROLLED | 05 | MN | MEDICAID |