Provider Demographics
NPI:1457311656
Name:MYUNG-SUP KIM MD PA
Entity Type:Organization
Organization Name:MYUNG-SUP KIM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYUNG-SUP
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-724-1646
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-0240
Mailing Address - Country:US
Mailing Address - Phone:301-724-1646
Mailing Address - Fax:301-724-7429
Practice Address - Street 1:RT 55 WEST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847
Practice Address - Country:US
Practice Address - Phone:304-257-1026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011406Medicaid
MD991702100Medicaid
MDS366OtherFEDERAL BS
02059300OtherBLACK LUNG
WV001708869OtherBLUE SHIELD
1120362OtherMAMSI
MDKCD4OtherBLUE SHIELD
02059300OtherBLACK LUNG
WV001708869OtherBLUE SHIELD
MDS366OtherFEDERAL BS
DG2425Medicare PIN