Basic Information
| Provider Information | |||||||||
| NPI: | 1841228608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | EON | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 834 CHESTNUT ST | ||||||||
| Address2: | SUITE G114 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155213000 | ||||||||
| FaxNumber: | 2155213002 | ||||||||
| Practice Location | |||||||||
| Address1: | 834 CHESTNUT ST | ||||||||
| Address2: | SUITE G114 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155213000 | ||||||||
| FaxNumber: | 2155213002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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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 | 207X00000X | 227333 | MA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | MD431878 | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 25MA08306100 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X | MD431878 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 25MA08306100 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00621736 | 01 | PA | RR MEDICARE | OTHER | 2010587 | 01 | PA | PBS | OTHER | 3318492000 | 01 | PA | INDEPENDENCE BLUE CROSS/KEYSTONE | OTHER |