Provider Demographics
NPI:1538294236
Name:KIM, PHILLIP S (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 PROSPECT AVE STE LG
Mailing Address - Street 2:1ST FL
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2539
Mailing Address - Country:US
Mailing Address - Phone:201-968-0303
Mailing Address - Fax:
Practice Address - Street 1:277 PROSPECT AVE LG
Practice Address - Street 2:1ST FL
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2570
Practice Address - Country:US
Practice Address - Phone:201-968-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00576300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU87755Medicare UPIN
NJ052620Medicare ID - Type Unspecified