Provider Demographics
NPI:1558499632
Name:KIM, KEVIN YOUNGMAN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:YOUNGMAN
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16326 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2645
Mailing Address - Country:US
Mailing Address - Phone:718-353-3988
Mailing Address - Fax:718-358-4090
Practice Address - Street 1:16326 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2645
Practice Address - Country:US
Practice Address - Phone:718-353-3988
Practice Address - Fax:718-358-4090
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP66781Medicare UPIN