Healthcare Provider Details

I. General information

NPI: 1023351830
Provider Name (Legal Business Name): TIMOTHY LELAND SHIH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number75441
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: