Provider Demographics
NPI:1760606537
Name:CENTER FOR INTERVENTIONAL SPINE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CENTER FOR INTERVENTIONAL SPINE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:HYUN-GEOL
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-977-0741
Mailing Address - Street 1:2424 ARDEN WAY STE 301
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2464
Mailing Address - Country:US
Mailing Address - Phone:916-977-0741
Mailing Address - Fax:916-977-0547
Practice Address - Street 1:2424 ARDEN WAY STE 301
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2464
Practice Address - Country:US
Practice Address - Phone:916-977-0741
Practice Address - Fax:916-977-0547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA609002081P2900X, 208VP0014X, 332900000X
CA2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG64120OtherCARL SHIN UPIN
CA1255473575OtherCARL SHIN NPI
CA5628017OtherNCPDP
CAG64120Medicare UPIN
CAG64120OtherCARL SHIN UPIN