1194738500 NPI number — DUCK J KIM MD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194738500 NPI number — DUCK J KIM MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUCK J KIM MD PC
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:
1194738500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/17/2007
NPI Reactivation Date:
03/09/2011

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 CORNELIA ST
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
PLATTSBURGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12901-2396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-563-8050
Provider Business Mailing Address Fax Number:
518-563-8352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 CORNELIA ST
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901-2396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-563-8050
Provider Business Practice Location Address Fax Number:
518-563-8352
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
DUCK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
518-563-8050

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  110604 , 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: 00511922 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000405443001 . This is a "BLUE SHIELD NORTHEASTERN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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