=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124432711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN IM, M.D., A MEDICAL CORP DEFINED.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2014
-----------------------------------------------------
Last Update Date | 08/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3785 WILSHIRE BLVD APT 1701
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-2891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-344-4855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3785 WILSHIRE BLVD APT 1701
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-2891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-344-4855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SUNG IM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 703-344-4855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A117206
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------