1982694626 NPI number — DR. MIRYE KIM MD

Table of content: DR. MIRYE KIM MD (NPI 1982694626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982694626 NPI number — DR. MIRYE KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
MIRYE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1982694626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E PENN SQ
Provider Second Line Business Mailing Address:
9TH FLOOR
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-3323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-425-9234
Provider Business Mailing Address Fax Number:
267-425-9299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 BOWMAN DRIVE
Provider Second Line Business Practice Location Address:
CHOP CARE NETWORK AT VIRTUA VOORHEES HOSPITAL
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-1548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-829-3191
Provider Business Practice Location Address Fax Number:
215-829-7123
Provider Enumeration Date:
10/25/2005

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: 2080N0001X , with the licence number:  25MA04699800 , 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: 3945502 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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