Basic Information
Provider Information | |||||||||
NPI: | 1255468690 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIM | ||||||||
FirstName: | LARRY | ||||||||
MiddleName: | INLIP | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 701 E MARSHALL STREET | ||||||||
Address2: | NRW 141 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 193804412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104315472 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 701 E MARSHALL STREET | ||||||||
Address2: | NRW 141 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 193804412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104315472 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2007 | ||||||||
LastUpdateDate: | 07/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD429858 | PA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 30042528 | 01 | PA | KEYSTONE MERCY | OTHER | 821632 | 01 | PA | 1ST HEALTH PRIORIT | OTHER | 000000213102 | 01 | PA | UNISON | OTHER | 1018981970001 | 05 | PA |   | MEDICAID | 1957622 | 01 | PA | HIGHMARK | OTHER | 2849064000 | 01 | PA | IBC | OTHER | 50070417 | 01 | PA | CAPITAL ADVANTAGE | OTHER | 20062997 | 01 | PA | AMERIHEALTH MERCY | OTHER |