Provider Demographics
NPI:1053347054
Name:SHIN, JOONG (MD)
Entity type:Individual
Prefix:
First Name:JOONG
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 KUMHO DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-9297
Mailing Address - Country:US
Mailing Address - Phone:330-576-0500
Mailing Address - Fax:330-576-0467
Practice Address - Street 1:822 KUMHO DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-9297
Practice Address - Country:US
Practice Address - Phone:330-576-0500
Practice Address - Fax:330-576-0467
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067515S207R00000X
OH35080113208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341906264028OtherCARESOURSE
OH729245OtherBUCKEYE COMMUNITY HEALTH
OH000000141920OtherANTHEM
OH0005691637OtherAETNA
OH2008384Medicaid
OH729245OtherBUCKEYE COMMUNITY HEALTH
OH$$$$$$$$$012OtherMEDICAL MUTUAL
OHF96159Medicare UPIN