Basic Information
| Provider Information | |||||||||
| NPI: | 1669754925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 16149 | ||||||||
| Address2: | |||||||||
| City: | RUMFORD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029160697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539625 | ||||||||
| FaxNumber: | 4014357069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 DUDLEY ST STE 190 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029053248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015538341 | ||||||||
| FaxNumber: | 4018682319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2011 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD039738 | DC | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0120X | MD16869 | RI | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.