1407157936 NPI number — CHRISTINE SUJUNG KIM RD

Table of content: CHRISTINE SUJUNG KIM RD (NPI 1407157936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407157936 NPI number — CHRISTINE SUJUNG KIM RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
CHRISTINE
Provider Middle Name:
SUJUNG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

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:
1407157936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/18/2019
NPI Reactivation Date:
11/27/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 SYLVAN AVE STE 301A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENGLEWOOD CLIFFS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07632-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-655-8483
Provider Business Mailing Address Fax Number:
201-461-2503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 SYLVAN AVE STE 301A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD CLIFFS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07632-2531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-655-8483
Provider Business Practice Location Address Fax Number:
201-461-2503
Provider Enumeration Date:
11/15/2010

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: 133V00000X , with the licence number:  86101311 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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