MEDICARE: DR. SANG O SHIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	M-9682	ID
2	207P00000X	Emergency Medicine Physician	11099	MT
3	207P00000X	Emergency Medicine Physician	10564	NV
4	207P00000X	Emergency Medicine Physician	MD2013-0642	NM

General Provider Information

NPI Number	:	1649226440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANG O SHIN MD

Provider Business Mailing Address
First Line	:	905 MADISON ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-6214
Country	:	US
Telephone Number	:	505-239-9435
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 SAN PEDRO DR SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-5180
Country	:	US
Telephone Number	:	265-171-1505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	04/08/2020

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Directions to “ DR. SANG O SHIN MD” Practice Location

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