1649345349 NPI number — WANG KI KIM MD

Table of content: WANG KI KIM MD (NPI 1649345349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649345349 NPI number — WANG KI KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
WANG
Provider Middle Name:
KI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1649345349
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54425 LAKESHORE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-627-3776
Provider Business Mailing Address Fax Number:
716-627-1162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOWANDA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-532-9202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084A0401X , with the licence number:  1233901 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 1233901 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 69440206 . This is a "LIONEL R JOHN CONTRACT HE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00020290301 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1505718 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5074651 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 005074651 . This is a "COMMUNITY BLUE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 074651 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1042076 . This is a "FIDELIS CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 69440206 . This is a "CATTARAUGUS INDIAN RESERV" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01429390 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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