Basic Information
Provider Information | |||||||||
NPI: | 1902845464 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIM | ||||||||
FirstName: | SANG | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020A BOAL AVE | ||||||||
Address2: |   | ||||||||
City: | BOALSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 168271509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142378627 | ||||||||
FaxNumber: | 8142380083 | ||||||||
Practice Location | |||||||||
Address1: | 300 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BRANCH | ||||||||
State: | NJ | ||||||||
PostalCode: | 077406303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7329236890 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 01/05/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 25MA073922 | NJ | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 211317 | NY | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 187384 | 01 | NJ | AMERIGROUP | OTHER | 3245799 | 01 | NJ | AETNA HMO | OTHER | 1175590 | 01 | NJ | HORIZON NJ HEALTH | OTHER | P2717905 | 01 | NJ | OXFORD | OTHER | 0007295366 | 01 | NJ | AETNA PPO | OTHER | 01000597300 | 01 | NJ | AMERICHOICE | OTHER | 223522719 | 01 | NJ | HORIZON BCBS | OTHER | 223522719 | 01 | NJ | UNITED HEALTHCARE | OTHER | 2302E1 | 01 | NJ | WELL CHOICE | OTHER | 7007553 | 01 | NJ | CIGNA | OTHER | 8889503 | 05 | NJ |   | MEDICAID | 2K7880 | 01 | NJ | HEALTHNET | OTHER | 0099584 | 01 | NJ | GHI | OTHER | 2226084000 | 01 | NJ | AMERIHEALTH HMO | OTHER |