Provider Demographics
NPI:1790781656
Name:YIM, ROGER S (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:S
Last Name:YIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13439 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-6304
Mailing Address - Country:US
Mailing Address - Phone:586-977-3900
Mailing Address - Fax:586-977-6084
Practice Address - Street 1:13439 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6304
Practice Address - Country:US
Practice Address - Phone:586-977-3900
Practice Address - Fax:586-977-6084
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4580230Medicaid
MI383479591OtherPPOM
700E001260OtherBCBS
MI4580230Medicaid
MI383479591OtherPPOM