Basic Information
| Provider Information | |||||||||
| NPI: | 1184613838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SOO | ||||||||
| MiddleName: | YOON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 OLD YORK RD | ||||||||
| Address2: | STE G20 | ||||||||
| City: | ABINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190013839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155171250 | ||||||||
| FaxNumber: | 2155170821 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157077725 | ||||||||
| FaxNumber: | 2157073945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD069981L | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0019708640001 | 05 | PA | MEDICAID |