NPIMap

Individual provider Active NPI

Michelle Jeena Im, DO

  • Family Medicine Physician
  • Shavertown, PA
National Provider Identifier
1134640717
Registry record updated Nov 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
OT018121 Issued in PA
Practice address
176 N Main St
Shavertown, PA 18708-1121
Phone
(570) 675-0900
NPI assigned
Jul 4, 2017
Last updated
Nov 15, 2021By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 15, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X OT018121 PA Primary

Addresses

Primary practice location

176 N Main St
Shavertown, PA 18708-1121

Mailing address

610 Wyoming Ave
Kingston, PA 18704-3702

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address michelle.im.1@21771.direct.athenahealth.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20201207001299 PA Practitioner - Family PracticePractitioner - Endocrinology 4486066982 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Commonwealth Physician Network LLCGroup PAC ID 2668696592, 63 clinicians
H2 Rehabilitation Extension Services LLCGroup PAC ID 6406131622, shared by 5 NPIs, 161 clinicians

Practice addresses (Care Compare)

176 N Main St
Shavertown, PA 18708-1121
Phone (570) 675-0900

1948 E 3Rd St
Suite C
Williamsport, PA 17701-3945
Phone (570) 327-1760

4 E Main St
Nanticoke, PA 18634-1602
Phone (570) 735-7474

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
89.17 of 100Reported as apm
Quality
78.34
Promoting interoperability
100
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of tissue1-10
Removal of skin lesions1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy, Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
OT018121PAMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Commonwealth Physician Network LLC Family Medicine CurrentSince Nov 15, 2023 Accepting new patients
Ecumenical Enterprises Inc Past Accepting new patients

Locations

610 Wyoming Ave
Kingston, PA 18704
Phone (570) 288-5441

610 Wyoming Ave
#2
Kingston, PA 18704
Phone (570) 714-1032

4 E Main St
Nanticoke, PA 18634
Phone (570) 258-3939

176 N Main St
Shavertown, PA 18708
Phone (570) 552-7150

Interoperability endpoints

  • Direct secure messaging: michelle.im.1@21771.direct.athenahealth.com

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Meadows Nursing and Rehabilitation CenterDallas, PA, CCN 395587 Skilled nursing facility Adp of the SNF Jan 1, 2023

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 37

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 37

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1499126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1636934400000",
    "number": "1134640717",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "610 WYOMING AVE",
            "city": "KINGSTON",
            "state": "PA",
            "postal_code": "187043702"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "176 N MAIN ST",
            "city": "SHAVERTOWN",
            "state": "PA",
            "postal_code": "187081121",
            "telephone_number": "570-675-0900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IM",
        "first_name": "MICHELLE",
        "middle_name": "JEENA",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-07-04",
        "last_updated": "2021-11-15",
        "certification_date": "2021-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "PA",
            "license": "OT018121",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "michelle.im.1@21771.direct.athenahealth.com",
            "affiliation": "N",
            "endpointDescription": "amr direct address",
            "address_1": "176 N Main St",
            "city": "Shavertown",
            "state": "PA",
            "country_code": "US",
            "postal_code": "187081121",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Shavertown, PA

Sources for this page

Verify at the official NPI Registry.