Basic Information
| Provider Information | |||||||||
| NPI: | 1558442038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SUCK | ||||||||
| MiddleName: | WON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2312 SOUTH 6TH STREET | ||||||||
| Address2: | SUITE F256 / 2B WEST | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2084P0800X | 20083 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 31694300 | 05 | WI | MEDICAID | 10387 | 05 | ND | MEDICAID | 1507269 | 01 | MN | MEDICA-CHOICE | OTHER | 260026103 | 01 | RR MEDICARE | OTHER | 0500298 | 05 | IA | MEDICAID | 765590 | 01 | ARAZ | OTHER | 7777470 | 05 | SD | MEDICAID | 009760800 | 05 | MN | MEDICAID | 108091 | 01 | MN | U CARE | OTHER | 5T619KI | 01 | MN | BCBS | OTHER | 088963 | 01 | MN | FAIRVIEW | OTHER | 1009170 | 01 | MN | PREFERRED ONE | OTHER | 1507269 | 01 | MN | MEDICA-PRIMARY | OTHER | HP22352 | 01 | MN | HEALTH PARTNERS | OTHER |