Healthcare Provider Details

I. General information

NPI: 1215998737
Provider Name (Legal Business Name): JACOB SUNG SIK KEUM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MORGAN ST
KEOKUK IA
52632-3497
US

IV. Provider business mailing address

PO BOX 97
GRIDLEY CA
95948-0097
US

V. Phone/Fax

Practice location:
  • Phone: 319-524-7150
  • Fax: 319-524-5317
Mailing address:
  • Phone: 530-846-9020
  • Fax: 530-846-9075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number227598
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number03623
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number227598
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number227598
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number20A13246
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO-04697
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: