Healthcare Provider Details

I. General information

NPI: 1659334498
Provider Name (Legal Business Name): MIRA SHIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 CENTER AVE STE 425
FORT LEE NJ
07024-4911
US

IV. Provider business mailing address

2050 CENTER AVE STE 425
FORT LEE NJ
07024-4911
US

V. Phone/Fax

Practice location:
  • Phone: 201-261-1000
  • Fax: 201-261-1188
Mailing address:
  • Phone: 201-261-1000
  • Fax: 201-261-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07929700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA07929700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA07929700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA07929700
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA07929700
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number25MA07929700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: