Provider Demographics
NPI:1376186080
Name:KIM, SAM EUNWOO (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:EUNWOO
Last Name:KIM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 N 15TH ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-4354
Mailing Address - Country:US
Mailing Address - Phone:201-889-2560
Mailing Address - Fax:
Practice Address - Street 1:1429 N 15TH ST APT 2F
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-4354
Practice Address - Country:US
Practice Address - Phone:201-889-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT027870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist