Provider Demographics
NPI:1770510901
Name:IM, SUNGGEUN SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SUNGGEUN
Middle Name:SAMUEL
Last Name:IM
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 1:11199 3 1/2 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-9370
Mailing Address - Country:US
Mailing Address - Phone:269-979-2501
Mailing Address - Fax:269-979-2501
Practice Address - Street 1:11199 31/2 MILE ROAD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-979-2501
Practice Address - Fax:269-979-2501
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-1695208600000X
CAC55339208600000X
MI31469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1077038Medicaid
MI1077038Medicaid
GUDG439ZMedicare PIN
0130302Medicare ID - Type Unspecified