Provider Demographics
NPI:1609308840
Name:KIM, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30035 16TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-3450
Mailing Address - Country:US
Mailing Address - Phone:253-886-9084
Mailing Address - Fax:
Practice Address - Street 1:SUNY STONY BROOK HOSPITAL
Practice Address - Street 2:DEPT OF MEDICINE HSC LEVEL 16
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-2058
Practice Address - Fax:631-444-2493
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program