Provider Demographics
NPI:1922139757
Name:TAE M SHIN, M.D. INC.
Entity Type:Organization
Organization Name:TAE M SHIN, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING OPERATIONS
Authorized Official - Prefix:MISS
Authorized Official - First Name:ROSE MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-577-8730
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0065
Mailing Address - Country:US
Mailing Address - Phone:805-577-8730
Mailing Address - Fax:805-991-4065
Practice Address - Street 1:4220 W 3RD ST
Practice Address - Street 2:SUITE #208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3450
Practice Address - Country:US
Practice Address - Phone:213-386-3554
Practice Address - Fax:805-991-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85170207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G851700Medicaid
CAG73491Medicare UPIN