=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255333795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KONGSEH LIM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 327 BEACH 19TH ST ST. JOHN'S EPISCOPAL HOSPITAL
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-869-7212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 650457
-----------------------------------------------------
City | FRESH MEADOWS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11365-0457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-875-4886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A128659-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------