Healthcare Provider Details

I. General information

NPI: 1720249121
Provider Name (Legal Business Name): SUSANNA H SHIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAUREL OAK RD
VOORHEES NJ
08043-4453
US

IV. Provider business mailing address

400 LAUREL OAK RD STE 105
VOORHEES NJ
08043-4455
US

V. Phone/Fax

Practice location:
  • Phone: 856-783-0191
  • Fax: 856-783-0264
Mailing address:
  • Phone: 856-922-9894
  • Fax: 856-922-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD039857
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA10852100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: