Healthcare Provider Details

I. General information

NPI: 1033679824
Provider Name (Legal Business Name): KEVIN SHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 REGIONAL CIR # BC
PINEHURST NC
28374-9863
US

IV. Provider business mailing address

1450 PROFESSIONAL PARK DR STE 150
WINSTON SALEM NC
27103-1307
US

V. Phone/Fax

Practice location:
  • Phone: 828-322-7546
  • Fax: 828-322-9927
Mailing address:
  • Phone: 336-724-2434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number202400393
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number202400393
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: