Provider Demographics
NPI:1275514424
Name:SHIN, CHARLES C (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:C
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 1:7255 OLD OAK BLVD
Mailing Address - Street 2:SUITE C111
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3329
Mailing Address - Country:US
Mailing Address - Phone:440-816-2730
Mailing Address - Fax:440-816-5352
Practice Address - Street 1:7255 OLD OAK BLVD
Practice Address - Street 2:SUITE C111
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3329
Practice Address - Country:US
Practice Address - Phone:440-816-2730
Practice Address - Fax:440-816-5352
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100181S207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0387764Medicaid
SH0440801Medicare ID - Type Unspecified
OH0387764Medicaid
OH0900640001Medicare NSC