=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407996622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAVELAND MEDICAL CENTER SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 10/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 W IRVING PARK RD #201
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-935-4470
-----------------------------------------------------
Fax | 773-935-5598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 W IRVING PARK RD #201
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-935-4470
-----------------------------------------------------
Fax | 773-935-5598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. DANIEL C SHIN
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 773-935-4470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------