MEDICARE: KEVIN IM, M.D., A MEDICAL CORP DEFINED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	A117206	CA

General Provider Information

NPI Number	:	1124432711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN IM, M.D., A MEDICAL CORP DEFINED.

Provider Business Mailing Address
First Line	:	3785 WILSHIRE BLVD APT 1701
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2891
Country	:	US
Telephone Number	:	703-344-4855
Fax Number	:

Provider Business Practice Location Address
First Line	:	3785 WILSHIRE BLVD APT 1701
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2891
Country	:	US
Telephone Number	:	703-344-4855
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SUNG IM
Credential	:	M.D.
Telephone Number	:	703-344-4855

Provider Enumeration Date	:	06/11/2014
Last Update Date	:	08/18/2014

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