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General NPI Number Information
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NPI Number | 1649519760
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Entity Type | Individual
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Provider Name | IL GON KIM M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/08/2013
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Last Update Date | 02/08/2013
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Provider Practice Location Address
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Address Line | 4060 ROUTE 220 HWY
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City | HUGHESVILLE
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State | PA
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Zip | 17737-8916
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Country | US
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Telephone | 570-584-4134
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Fax |
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Provider Business Mailing Address
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Address Line | 420 S MAIN ST
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City | HUGHESVILLE
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State | PA
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Zip | 17737-1630
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Country | US
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Telephone | 570-584-4134
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD-028191-L
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License Number State | PA
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