Provider Demographics
NPI:1184829244
Name:SE JUNG SHIN MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SE JUNG SHIN MD PROFESSIONAL CORPORATION
Other - Org Name:CORNELL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SE JUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:503-646-8500
Mailing Address - Street 1:13305 NW CORNELL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5987
Mailing Address - Country:US
Mailing Address - Phone:503-646-8500
Mailing Address - Fax:503-646-8200
Practice Address - Street 1:13305 NW CORNELL ROAD, SUITE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229
Practice Address - Country:US
Practice Address - Phone:503-646-8500
Practice Address - Fax:503-646-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR36696207P00000X, 207PE0004X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184829244OtherNPI NUMBER
OR138485Medicare PIN