Provider Demographics
NPI:1124051784
Name:TAE I SHYNN
Entity type:Organization
Organization Name:TAE I SHYNN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAE
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-735-7590
Mailing Address - Street 1:121 S PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTICOKE
Mailing Address - State:PA
Mailing Address - Zip Code:18634-2456
Mailing Address - Country:US
Mailing Address - Phone:570-735-7590
Mailing Address - Fax:570-735-0186
Practice Address - Street 1:121 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-2456
Practice Address - Country:US
Practice Address - Phone:570-735-7590
Practice Address - Fax:570-735-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA097426Medicare ID - Type Unspecified