Provider Demographics
NPI:1407996622
Name:WAVELAND MEDICAL CENTER SC
Entity Type:Organization
Organization Name:WAVELAND MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-935-4470
Mailing Address - Street 1:840 W IRVING PARK RD
Mailing Address - Street 2:#201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3011
Mailing Address - Country:US
Mailing Address - Phone:773-935-4470
Mailing Address - Fax:773-935-5598
Practice Address - Street 1:840 W IRVING PARK RD
Practice Address - Street 2:#201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:773-935-4470
Practice Address - Fax:773-935-5598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty