Healthcare Provider Details

I. General information

NPI: 1407996622
Provider Name (Legal Business Name): WAVELAND MEDICAL CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 W IRVING PARK RD #201
CHICAGO IL
60613-3011
US

IV. Provider business mailing address

840 W IRVING PARK RD #201
CHICAGO IL
60613-3011
US

V. Phone/Fax

Practice location:
  • Phone: 773-935-4470
  • Fax: 773-935-5598
Mailing address:
  • Phone: 773-935-4470
  • Fax: 773-935-5598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL C SHIN
Title or Position: PHYSICIAN
Credential: M.D
Phone: 773-935-4470