1255490348 NPI number — AGNES KIM M.D.

Table of content: AGNES KIM M.D. (NPI 1255490348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255490348 NPI number — AGNES KIM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
AGNES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIM
Provider Other First Name:
SERYOUNG
Provider Other Middle Name:
AGNES
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255490348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
263 FARMINGTON AVE
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06030-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-679-7503
Provider Business Mailing Address Fax Number:
860-679-1610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
CARDIOLOGY
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06030-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-679-3343
Provider Business Practice Location Address Fax Number:
860-679-4256
Provider Enumeration Date:
12/06/2006

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: 207RC0000X , with the licence number:  044570 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1255490348 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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