Basic Information
| Provider Information | |||||||||
| NPI: | 1518929595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YIM | ||||||||
| FirstName: | JEREMIAH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31382 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122563682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 339 HICKS STREET | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187801124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 208118 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 02411618 | 05 | NY | MEDICAID |