Provider Demographics
NPI:1659334498
Name:SHIN, MIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 CENTER AVE
Mailing Address - Street 2:STE 425
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-4911
Mailing Address - Country:US
Mailing Address - Phone:201-261-1000
Mailing Address - Fax:201-261-1188
Practice Address - Street 1:2050 CENTER AVE
Practice Address - Street 2:STE 425
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-4911
Practice Address - Country:US
Practice Address - Phone:201-261-1000
Practice Address - Fax:201-261-1188
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07929700174400000X, 208100000X, 2081H0002X, 2081P2900X, 2081S0010X, 2083S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9404330OtherPHCS (PRIVATE HEALTHCARE SYSTEMS)
NJ20-8831104OtherTAX ID #
NJ20-8831104OtherMULTIPLAN
NJ7687754OtherAETNA PPO #
NJP3635893OtherOXFORD #
NJ20-8831104OtherFAMILY CHOICE HEALTH
NJ3K6327OtherHEALTHNET (PHS)
NJ161568OtherGHI
NJ20-8831104OtherCONSUMER HEALTH NETWORK(CHN)
NY3696X1OtherEMPIRE BLUECROSSBLUESHIELD NY (WELL CHOICE)
NJ1151716OtherAETNA HMO #
NJ1749400OtherCIGNA
NJ3K2116OtherHEALTHNET #
NJ3K2116OtherHEALTHNET #