Provider Demographics
NPI:1588655195
Name:SHIN, JORDAN T (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:T
Last Name:SHIN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:YAW 5 CARDIAC UNIT ASSOCIATES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-6750
Practice Address - Fax:617-724-6767
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209706207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA458021OtherTUFTS HEALTH PLAN
MAJ25211OtherBCBS MA
MA0198447Medicaid
MA0198447Medicaid
MA458021OtherTUFTS HEALTH PLAN