Provider Demographics
NPI:1063498228
Name:SHEEN, KWANGSUP K (MD)
Entity Type:Individual
Prefix:DR
First Name:KWANGSUP
Middle Name:K
Last Name:SHEEN
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 1:1400 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PECKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18452-2009
Mailing Address - Country:US
Mailing Address - Phone:570-383-5511
Mailing Address - Fax:
Practice Address - Street 1:1400 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-2009
Practice Address - Country:US
Practice Address - Phone:570-383-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056601L207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001746129Medicaid
PA861181OtherHIGHMARK BLUE SHIELD
PA020420NUTMedicare PIN
PA020420Medicare ID - Type Unspecified
PAG08404Medicare UPIN