Healthcare Provider Details

I. General information

NPI: 1275466872
Provider Name (Legal Business Name): SOOJIN LIM
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

V. Phone/Fax

Practice location:
  • Phone: 631-505-2119
  • Fax:
Mailing address:
  • Phone: 631-902-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number753184-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: