Basic Information
| Provider Information | |||||||||
| NPI: | 1548363740 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMBULATORY ANESTHESIA SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 639 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207250639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013170020 | ||||||||
| FaxNumber: | 3013170028 | ||||||||
| Practice Location | |||||||||
| Address1: | 10730 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRFOX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013170020 | ||||||||
| FaxNumber: | 3013170028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | CHUL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3013170020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2358917 | 01 | PA | AETNA | OTHER | 2358917 | 01 | VA | AETNA | OTHER | 9105 | 01 | DC | BLUE SHIELD | OTHER | 268616 | 01 | VA | UNITED HEALTH CARE | OTHER | 2358917 | 01 | DC | AETNA | OTHER |