Provider Demographics
NPI:1679677736
Name:IM, BRIAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:S
Last Name:IM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:240 E 38TH ST
Mailing Address - Street 2:15TH FLOOR, ROOM 15-54
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2708
Mailing Address - Country:US
Mailing Address - Phone:212-263-6110
Mailing Address - Fax:212-263-6251
Practice Address - Street 1:240 E 38TH ST
Practice Address - Street 2:15TH FLOOR, ROOM 15-54
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2708
Practice Address - Country:US
Practice Address - Phone:212-263-6110
Practice Address - Fax:212-263-6251
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08099200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0107778Medicaid