Provider Demographics
NPI:1851454615
Name:KIM, SAM Y (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:Y
Last Name:KIM
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 1:1919 LATHROP ST
Mailing Address - Street 2:STE 103
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-456-7768
Mailing Address - Fax:907-456-4045
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:STE 103
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-456-7768
Practice Address - Fax:907-456-4045
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5779207Y00000X
IN01051686A207Y00000X
CAA99387207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0304Medicaid
AKK161777Medicare PIN