1518166420 NPI number — BERNARD HAKSOO KIM MD

Table of content: BERNARD HAKSOO KIM MD (NPI 1518166420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518166420 NPI number — BERNARD HAKSOO KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
BERNARD
Provider Middle Name:
HAKSOO
Provider Name Prefix Text:
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:
KIM
Provider Other First Name:
BERNARD
Provider Other Middle Name:
HAKSOO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1518166420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 PROSPECT AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
HACKENSACK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07601-1997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-996-4849
Provider Business Mailing Address Fax Number:
551-996-5703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 PROSPECT AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-1997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-996-4849
Provider Business Practice Location Address Fax Number:
551-996-5703
Provider Enumeration Date:
07/12/2007

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:  248070 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0001X , with the licence number: 25MA07795000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02961053 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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