MEDICARE: SUN S KIM RN PC

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	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	279972	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	279972	OTHER	MA	MASSACHUSETTS LICENSE

General Provider Information

NPI Number	:	1992942148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUN S KIM RN PC

Provider Business Mailing Address
First Line	:	PO BOX 415348
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-5348
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	328 SHREWSBURY ST
Second Line	:	DEPARTMENT OF PSYCHIATRY
City	:	WORCESTER
State	:	MA
Zip	:	01604-4613
Country	:	US
Telephone Number	:	508-334-2537
Fax Number	:	508-334-4320

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2009
Last Update Date	:	05/01/2014

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