1538372297 NPI number — INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT

Table of content: DR. JOHN YONGSOK KIM D.C. (NPI 1205016326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538372297 NPI number — INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538372297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1523
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONY BROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11790-0907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-444-0910
Provider Business Mailing Address Fax Number:
631-689-3814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 NESCONSET HWY
Provider Second Line Business Practice Location Address:
BLDG 24C
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11790-2555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-444-0910
Provider Business Practice Location Address Fax Number:
631-689-3814
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ERMISH
Authorized Official First Name:
LAURINE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
631-941-0187

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 096933 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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