1194738500 NPI number — DUCK J KIM MD PC

Table of content: (NPI 1194738500)

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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