MEDICARE: DR. SUNGJIN IM PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	024766	NY
2	103TC0700X	Clinical Psychologist	276794	KY

General Provider Information

NPI Number	:	1275222127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUNGJIN IM PHD

Provider Business Mailing Address
First Line	:	1906 COLLEGE HEIGHTS BLVD # 3021
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-1000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 COLLEGE HEIGHTS BLVD # 3021
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-1000
Country	:	US
Telephone Number	:	775-393-0307
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2023
Last Update Date	:	05/05/2023

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