Provider Demographics
NPI:1437269685
Name:SHIM, CHUNGJA C
Entity Type:Individual
Prefix:
First Name:CHUNGJA
Middle Name:C
Last Name:SHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301
Mailing Address - Country:US
Mailing Address - Phone:724-228-3400
Mailing Address - Fax:724-228-7040
Practice Address - Street 1:406 W OAK STREET
Practice Address - Street 2:TITUSVILLE AREA HOSPITAL
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354
Practice Address - Country:US
Practice Address - Phone:814-827-1851
Practice Address - Fax:814-827-7259
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD02206SE207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA009579700001Medicaid
PA009579700001Medicaid
D68789Medicare UPIN