Healthcare Provider Details

I. General information

NPI: 1184312464
Provider Name (Legal Business Name): SHIM ROH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0818
US

IV. Provider business mailing address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0818
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-5214
  • Fax: 434-243-9143
Mailing address:
  • Phone: 434-924-5214
  • Fax: 434-243-9143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0101289309
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: