Healthcare Provider Details

I. General information

NPI: 1669796710
Provider Name (Legal Business Name): SOON JA KIM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5808 MAIN ST
ELKRIDGE MD
21075-5105
US

IV. Provider business mailing address

5808 MAIN ST
ELKRIDGE MD
21075-5105
US

V. Phone/Fax

Practice location:
  • Phone: 410-796-7730
  • Fax: 410-379-1537
Mailing address:
  • Phone: 410-796-7730
  • Fax: 410-379-1537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SOON JA KIM
Title or Position: PRESIDENT
Credential: MD
Phone: 410-796-7730