Provider Demographics
NPI:1598788762
Name:KHIM, BRYAN SUNGKOO (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:SUNGKOO
Last Name:KHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8815 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4111
Mailing Address - Country:US
Mailing Address - Phone:410-480-1800
Mailing Address - Fax:410-480-2899
Practice Address - Street 1:8815 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:SUITE B
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4111
Practice Address - Country:US
Practice Address - Phone:410-480-1800
Practice Address - Fax:410-480-2899
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD50978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD019440900Medicaid
04720930647OtherMEDICAL EDUCATION NO.
MDG35959Medicare UPIN
748QMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.