Healthcare Provider Details

I. General information

NPI: 1205877859
Provider Name (Legal Business Name): SUH KANG KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date: 07/16/2013
Reactivation Date: 08/07/2013

III. Provider practice location address

7600 OSLER DR SUITE 310
TOWSON MD
21204-7735
US

IV. Provider business mailing address

7600 OSLER DR SUITE 310
TOWSON MD
21204-7735
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-8598
  • Fax: 410-296-3444
Mailing address:
  • Phone: 410-337-8598
  • Fax: 410-296-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0012726
License Number StateMD

VII. Legacy identifiers

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

# 1
Identifier005701100
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: