Provider Demographics
NPI:1083698831
Name:NAM, SHIN I (MD)
Entity Type:Individual
Prefix:
First Name:SHIN
Middle Name:I
Last Name:NAM
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 1:1200 MAPLE ROAD
Mailing Address - Street 2:SUITE 3309
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-1439
Mailing Address - Country:US
Mailing Address - Phone:815-723-9351
Mailing Address - Fax:815-723-9823
Practice Address - Street 1:1200 MAPLE ROAD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-1439
Practice Address - Country:US
Practice Address - Phone:815-723-9351
Practice Address - Fax:815-723-9823
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360525382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052538Medicaid
IL36-052538Medicaid
IL36-052538Medicaid
D13761Medicare UPIN
ILD13761Medicare UPIN