Provider Demographics
NPI:1093968737
Name:KIM, SHINE H (MD)
Entity Type:Individual
Prefix:DR
First Name:SHINE
Middle Name:H
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 COLDEN ST APT 420
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4848
Mailing Address - Country:US
Mailing Address - Phone:646-644-0716
Mailing Address - Fax:
Practice Address - Street 1:4210 COLDEN ST APT 420
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4848
Practice Address - Country:US
Practice Address - Phone:646-644-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39207R00000X, 207RH0002X, 208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1234567810Medicaid
NY1234567810Medicaid
NY1234567810Medicare UPIN
NY1234567810Medicare PIN
NY1234567810Medicare NSC