Basic Information
Provider Information
NPI: 1003800087
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHIN
FirstName: ROBERT
MiddleName: B
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3611 S REED RD
Address2: SUITE 107
City: KOKOMO
State: IN
PostalCode: 469023828
CountryCode: US
TelephoneNumber: 7654538644
FaxNumber: 7654538667
Practice Location
Address1: 3611 S REED RD
Address2: SUITE 107
City: KOKOMO
State: IN
PostalCode: 469023828
CountryCode: US
TelephoneNumber: 7654538644
FaxNumber: 7654538667
Other Information
ProviderEnumerationDate: 09/07/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207KA0200X01030149INY Allopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy

ID Information
IDTypeStateIssuerDescription
00000008606801INANTHEMOTHER
35163971900101INTRICAREOTHER


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