SE JUNG SHIN MD PROFESSIONAL CORPORATION (NPI# 1184829244) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1184829244 |
| Entity Type | Organization |
| Organization Name | SE JUNG SHIN MD PROFESSIONAL CORPORATION |
| Other Organization Name | CORNELL URGENT CARE |
| Practice Address |
13305 Nw Cornell Road, Suite C Portland OR 97229 |
| Mailing Address |
13305 Nw Cornell Rd Suite C Portland OR 97229-5987 |
| Practice Telephone | 5036468500 |
| Practice Fax Number | 5036468200 |
| Mailing Telephone | 5036468500 |
| Mailing Fax Number | 5036468200 |
| Enumeration Date | 2007-06-19 |
| Last Update Date | 2015-04-16 |
| Authorized Official Name | DR. SE JUNG SHIN (PRESIDENT) |
| Authorized Official Telephone | 5036468500 |
| Authorized Official Credential | M.D. PC |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207PE0004X |
Emergency Medicine Specialization: Emergency Medical Services |
36696 | OR | Allopathic & Osteopathic Physicians |
| N | 207PP0204X |
Emergency Medicine Specialization: Pediatric Emergency Medicine |
36696 | OR | Allopathic & Osteopathic Physicians |
| Y | 207P00000X | Emergency Medicine | 36696 | OR | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| NPI NUMBER | 1184829244 | 01 |
| Other Name | Type Code |
|---|---|
| Cornell Urgent Care | Doing Business As Name - Organization |
| Entity Type | Entity Name | Entity Address |
|---|---|---|
| Oregon Corporations, Companies and Business Names | SE JUNG SHIN MD PROFESSIONAL CORPORATION | 13305 Nw Cornell Rd Ste C, Portland, OR 97229 |
| Street Address |
13305 NW CORNELL ROAD, SUITE C |
| City | PORTLAND |
| State | OR |
| Zip Code | 97229 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1851919906 | Anjana Rajan | Counselor | Lifeworks Northwest, 14600 Nw Cornell Rd, Portland, OR 97229 | 2020-07-06 |
| 1871138453 | Kedrick Starr | Case Manager/Care Coordinator | 14600 Nw Cornell Rd., Portland, OR 97229 | 2019-11-07 |
| 1477102689 | Raquel A Bishop | Nurse Practitioner | 12400 Nw Cornell Rd Ste 100, Portland, OR 97229 | 2019-09-10 |
| 1669026134 | Alexandra Elizabeth Lodwig | Speech-Language Pathologist | 255 Nw Lost Springs Terrace Apt 304, Portland, OR 97229 | 2019-08-01 |
| 1003316043 | Jenny Lavonne Thom | Counselor | 15220 Nw Laidlaw Rd., Suite 280, Portland, OR 97229 | 2018-02-16 |
| 1194230664 | Ankita Guchait | Case Manager/Care Coordinator | 14600 Nw Cornell Rd, Portland, OR 97229 | 2017-12-06 |
| 1568988913 | Hannah Hendrix Klingelheber | Speech-Language Pathologist | 15605 Nw Ryegrass St., Portland, OR 97229 | 2017-08-17 |
| 1548791213 | Adeline Mitchell | Registered Nurse | 14600 Sw Cornell Rd., Portland, OR 97229 | 2017-03-24 |
| 1538610670 | Crystal Graves | Peer Specialist | 14600 Nw Cornell, Portland, OR 97229 | 2016-10-24 |
| 1639533185 | Evelin James | Dental Hygienist | 5879 Nw Lark Meadow Ter, Portland, OR 97229 | 2016-04-11 |
| Find all providers in zip 97229 | ||||
| Taxonomy Code | 207P00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Emergency Medicine |
| An emergency physician focuses on the immediate decision making and action necessary to prevent death or any further disability both in the pre-hospital setting by directing emergency medical technicians and in the emergency department. The emergency physician provides immediate recognition, evaluation, care, stabilization and disposition of a generally diversified population of adult and pediatric patients in response to acute illness and injury. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: added definition, added source; 7/1/2011: mofified source] - Additional Resources: American Board of Emergency Medicine, 2007. http://www.abem.org/public/; American Osteopathic Board of Emergency Medicine, 2007. http://www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Emergency Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Emergency Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1376074674 | Samuel B Potter | Emergency Medicine | Maine Medical Center, 22 Bramhall Street, Portland, ME 04102 | 2017-03-27 |
| 1912361718 | Bryce Edwards | Emergency Medicine | 3181 Sw Sam Jackson Park Road, Ohsu, Portland, OR 97239 | 2016-04-07 |
| 1073907978 | Karen Ta | Emergency Medicine | 10300 Se Main St, Portland, OR 97216 | 2015-03-27 |
| 1104210921 | Elizabeth Hatfield | Emergency Medicine | 3181 Sw Sam Jackson Park Rd # Cdw, Portland, OR 97239-3011 | 2015-03-19 |
| 1699171918 | Stephen Boyer | Emergency Medicine | 3708 Sw Lyle Ct, Portland, OR 97221-3963 | 2014-11-13 |
| 1679991590 | Meaghan Dehning | Emergency Medicine | 3181 Sw Sam Jackson Park Rd # Em, Portland, OR 97239-3011 | 2014-03-29 |
| 1942647185 | Jason F Hine | Emergency Medicine | E1 Clairmont Ct, Portland, ME 04103-4459 | 2013-05-29 |
| 1487900742 | Aaron Vitells | Emergency Medicine | 2424 Ne 41st Ave, Portland, OR 97212-5423 | 2012-07-24 |
| 1073870895 | Marcus Alyn Chiodo | Emergency Medicine | 10000 Se Main St Ste 40, Adventist Medical Center - The Pavilion, Portland, OR 97216-2461 | 2012-04-18 |
| 1184913147 | Jerry L Lawrence | Emergency Medicine | 11705 Nw Timberview Ln, Apt 204, Portland, OR 97229-6659 | 2011-03-30 |
| Find all providers in PORTLAND | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.