Provider Demographics
NPI:1265520779
Name:KIM, SAMUEL W (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1617
Mailing Address - Country:US
Mailing Address - Phone:516-263-8836
Mailing Address - Fax:
Practice Address - Street 1:1 COLUMBIA ST
Practice Address - Street 2:DRA IMAGING, PC
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3923
Practice Address - Country:US
Practice Address - Phone:845-454-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2318812085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02802124Medicaid