Provider Demographics
NPI:1295005049
Name:KIM, SU JUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:SU JUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MEDICAL CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-1254
Mailing Address - Country:US
Mailing Address - Phone:215-997-2101
Mailing Address - Fax:215-997-2102
Practice Address - Street 1:51 MEDICAL CAMPUS DR
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1254
Practice Address - Country:US
Practice Address - Phone:215-997-2101
Practice Address - Fax:215-997-2102
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD446353207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102960510Medicaid
PA369427Medicare PIN