1154879344 NPI number — PDSC PC

Table of content: JOSHUA W KIM MD (NPI 1740391952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154879344 NPI number — PDSC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PDSC 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:
1154879344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2603 VINEWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81005-3370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-924-8535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2041 PEPPER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81005-3276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-564-6464
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BIELECKI
Authorized Official First Name:
PAWEL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OW
Authorized Official Telephone Number:
719-924-8535

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  8809 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8809 . This is a "STATE OF COLORADO BOARD OF EXAMINERS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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