1942241518 NPI number — MYUNGDUK ROGER KIM MD

Table of content: MYUNGDUK ROGER KIM MD (NPI 1942241518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942241518 NPI number — MYUNGDUK ROGER KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
MYUNGDUK
Provider Middle Name:
ROGER
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:
KIM
Provider Other First Name:
ROGER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1942241518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BROOKDALE PLAZA, STRAUSBERG SUITE 244
Provider Second Line Business Mailing Address:
BROOKDALE UNIVERSITY HOSPITAL AND MEDICAL CENTER
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-240-5628
Provider Business Mailing Address Fax Number:
718-240-6513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BROOKDALE PLZ
Provider Second Line Business Practice Location Address:
ROOM 244
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11212-3139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-240-5668
Provider Business Practice Location Address Fax Number:
718-240-6513
Provider Enumeration Date:
06/08/2006

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: 208000000X , with the licence number:  178690 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 178690 , 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: 01404448 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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