1922139757 NPI number — TAE M SHIN, M.D. INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922139757 NPI number — TAE M SHIN, M.D. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAE M SHIN, M.D. INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922139757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMI VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93062-0065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-577-8730
Provider Business Mailing Address Fax Number:
805-991-4065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4220 W 3RD ST
Provider Second Line Business Practice Location Address:
SUITE #208
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90020-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-386-3554
Provider Business Practice Location Address Fax Number:
805-991-4065
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA
Authorized Official First Name:
ROSE MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BILLING OPERATIONS
Authorized Official Telephone Number:
805-577-8730

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  G85170 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G851700 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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