1306940705 NPI number — DR. STANLEY I KIM MD

Table of content: DR. STANLEY I KIM MD (NPI 1306940705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306940705 NPI number — DR. STANLEY I KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
STANLEY
Provider Middle Name:
I
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1306940705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 COURT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEENE
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03431-1718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
909-624-7211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 E 28TH ST STE 401
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55407-3723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-863-0200
Provider Business Practice Location Address Fax Number:
612-863-0235
Provider Enumeration Date:
09/08/2006

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: 207RX0202X , with the licence number:  74165 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X , with the licence number: 22994 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 25272 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: A42574 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00A425740 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".