=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760665327
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAE WON SHIN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2007
-----------------------------------------------------
Last Update Date | 10/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 EASTMORELAND AVE STE 370
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-7542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-758-7888
-----------------------------------------------------
Fax | 901-387-5153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1068 CRESTHAVEN RD STE 300
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-0809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 69706
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 69706
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084E0001X
-----------------------------------------------------
Taxonomy Name | Epilepsy Physician
-----------------------------------------------------
License Number | 69706
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------