Healthcare Provider Details

I. General information

NPI: 1477349330
Provider Name (Legal Business Name): CHAESEONG YIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVENUE MAIN BUILDING, ROOM 704
NEW YORK NY
10029
US

IV. Provider business mailing address

12 GEUMOSAN-RO 6-GIL
GUM-SI GYEONGSANGBUK-DO
39223
KR

V. Phone/Fax

Practice location:
  • Phone: 212-423-6771
  • Fax: 212-423-8099
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: