1568807212 NPI number — BYUNGHEE KEVIN KIM D.P.M

Table of content: (NPI 1275040198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568807212 NPI number — BYUNGHEE KEVIN KIM D.P.M

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
BYUNGHEE
Provider Middle Name:
KEVIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M
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:
1568807212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2299 POST ST 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94115-3473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-289-6624
Provider Business Mailing Address Fax Number:
800-808-1779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 BISHOP LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-459-3338
Provider Business Practice Location Address Fax Number:
502-459-7509
Provider Enumeration Date:
05/08/2013

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: 213E00000X , with the licence number:  00401 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: E5000 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000863362 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P01291447 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100267930 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50063970 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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