Provider Demographics
NPI:1508048943
Name:SHIBUMI, LLC
Entity Type:Organization
Organization Name:SHIBUMI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDELL
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-313-4060
Mailing Address - Street 1:908 WORTH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2064
Mailing Address - Country:US
Mailing Address - Phone:513-313-4060
Mailing Address - Fax:513-558-5203
Practice Address - Street 1:310 STRAIGHT ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1019
Practice Address - Country:US
Practice Address - Phone:513-559-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051891208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty