Basic Information
| Provider Information | |||||||||
| NPI: | 1720020647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHINA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 HOSPITAL DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717014651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708372888 | ||||||||
| FaxNumber: | 8708372892 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 HOSPITAL DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708372888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 23428 | KY | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | E-11636 | AR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100020000A | 05 | IN | MEDICAID | 64234289 | 05 | KY | MEDICAID |