Healthcare Provider Details

I. General information

NPI: 1710081054
Provider Name (Legal Business Name): KYUNG H KIM MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 E PROSPECT AVE
MT VERNON NY
10550-1605
US

IV. Provider business mailing address

262 E PROSPECT AVE
MT VERNON NY
10550-1605
US

V. Phone/Fax

Practice location:
  • Phone: 914-668-2600
  • Fax: 914-668-6102
Mailing address:
  • Phone: 914-668-2600
  • Fax: 914-668-6102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number150848
License Number StateNY

VIII. Authorized Official

Name: KYUNG H KIM
Title or Position: MD
Credential: MD PC
Phone: 914-668-2600