Basic Information
| Provider Information | |||||||||
| NPI: | 1528353273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SOO CHONG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 ESSEX ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076018566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519961140 | ||||||||
| FaxNumber: | 5519960543 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 ESSEX ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519961140 | ||||||||
| FaxNumber: | 5519960543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 25MA09671600 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0459810 | 05 | NJ | MEDICAID |