Provider Demographics
NPI:1023081882
Name:JOH, SHIN (MD)
Entity type:Individual
Prefix:
First Name:SHIN
Middle Name:
Last Name:JOH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2899
Mailing Address - Country:US
Mailing Address - Phone:815-673-5533
Mailing Address - Fax:815-673-2554
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2899
Practice Address - Country:US
Practice Address - Phone:815-673-5533
Practice Address - Fax:815-673-2554
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD09776Medicare UPIN
IL211480Medicare ID - Type Unspecified