Healthcare Provider Details

I. General information

NPI: 1124656921
Provider Name (Legal Business Name): SAMUEL JACOB SHINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

IV. Provider business mailing address

6551 CENTERVILLE BUSINESS PKWY STE 120
CENTERVILLE OH
45459-2696
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number34.017659
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: