Healthcare Provider Details

I. General information

NPI: 1639146558
Provider Name (Legal Business Name): SUNNY R KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 ROCKWELL DR NE STE B
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

6005 ROCKWELL DR NE STE B
CEDAR RAPIDS IA
52402-7228
US

V. Phone/Fax

Practice location:
  • Phone: 319-393-1320
  • Fax: 319-393-1350
Mailing address:
  • Phone: 319-393-1320
  • Fax: 319-393-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35982
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1468462
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: