Provider Demographics
NPI:1750483723
Name:SHIN, TAE MIN (MD)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:MIN
Last Name:SHIN
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 1:1245 WILSHIRE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-482-2992
Mailing Address - Fax:213-482-2999
Practice Address - Street 1:1245 WILSHIRE BLVD., SUITE 400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-482-2992
Practice Address - Fax:213-482-2999
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85170207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G851700Medicaid
CAG73491Medicare UPIN
CAWG85170EMedicare ID - Type Unspecified