Provider Demographics
NPI:1336195692
Name:UM, KI-BONG (MD)
Entity Type:Individual
Prefix:
First Name:KI-BONG
Middle Name:
Last Name:UM
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 1:501 N MAIN ST
Mailing Address - Street 2:PO BOX 625
Mailing Address - City:ROBERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27871-9567
Mailing Address - Country:US
Mailing Address - Phone:252-795-4192
Mailing Address - Fax:252-795-4739
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROBERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27871-9567
Practice Address - Country:US
Practice Address - Phone:252-795-4192
Practice Address - Fax:252-795-4739
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25751208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC84530OtherBC
NC8984530Medicaid
NC20503OtherCIGNA
NC202688Medicare PIN
NC20503OtherCIGNA