=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881965804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEENS MEDICAL SOUTH PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2012
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3939 63RD ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-3648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-397-0005
-----------------------------------------------------
Fax | 888-388-5171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3939 63RD ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-3648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-397-0005
-----------------------------------------------------
Fax | 888-388-5171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUNG KIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 646-397-0005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 105860
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------