Provider Demographics
NPI:1669553954
Name:LIN, SHAO-POW (MD, PHD)
Entity type:Individual
Prefix:
First Name:SHAO-POW
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 202
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:
Practice Address - Street 1:4101 WAGON TRAIL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-4426
Practice Address - Country:US
Practice Address - Phone:702-942-4123
Practice Address - Fax:702-942-4124
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020137102085R0202X
NV130822085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00769702OtherRR MEDICARE
NV1669553954Medicaid
NVVBZ628ZMedicare PIN