Basic Information
| Provider Information | |||||||||
| NPI: | 1043207012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | YOUNG | ||||||||
| MiddleName: | WOOK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 LANGHORNE NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | LANGHORNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190471201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157102196 | ||||||||
| FaxNumber: | 2157102408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 LANGHORNE NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | LANGHORNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190471201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157102196 | ||||||||
| FaxNumber: | 2157102408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 04/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD031232L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0010454820001 | 05 | PA | MEDICAID |