1336296722 NPI number — K. KWANG SOO, M.D., S.C.

Table of content: (NPI 1336296722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336296722 NPI number — K. KWANG SOO, M.D., S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
K. KWANG SOO, M.D., S.C.
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:
1336296722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 170526
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53217-8046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-228-8300
Provider Business Mailing Address Fax Number:
414-228-6303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2691 N LAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-228-8300
Provider Business Practice Location Address Fax Number:
414-228-6303
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SOO
Authorized Official First Name:
KAM
Authorized Official Middle Name:
KWANG
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-964-6077

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  19331 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 301 529 00 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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