Basic Information
| Provider Information | |||||||||
| NPI: | 1841424074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SUNG | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIM | ||||||||
| OtherFirstName: | SUNG | ||||||||
| OtherMiddleName: | TAE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 HIGHLAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GLEN RIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070281521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739693800 | ||||||||
| FaxNumber: | 9739693232 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HIGHLAND AVE STE 100B | ||||||||
| Address2: | |||||||||
| City: | GLEN RIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070281521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739693800 | ||||||||
| FaxNumber: | 9739693232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA09997400 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.