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General NPI Number Information
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NPI Number | 1982855995
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Entity Type | Organization
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Legal Business Name | BRIDGEPORT MEDICAL CLINIC PLLC
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Dates
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Enumeration Date | 10/08/2008
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Last Update Date | 05/03/2023
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Provider Practice Location Address
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Address Line | 511 10TH AVE SE
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City | PUYALLUP
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State | WA
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Zip | 98372-3875
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Country | US
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Telephone | 253-845-7566
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Fax |
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Provider Business Mailing Address
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Address Line | 152 S 295TH PL
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City | FEDERAL WAY
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State | WA
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Zip | 98003-3659
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Country | US
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Telephone | 253-797-9234
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Fax | 253-588-4986
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Authorized Official
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Title or Position | MEMBER
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Name | DR. DENNIS JOOYOUNG KIM
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Credential | M.D.
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Telephone | 253-797-9234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | MD00041157
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License Number State | WA
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