Basic Information
| Provider Information | |||||||||
| NPI: | 1306846167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | YOUNG | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5655 HUDSON DRIVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442364451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306553800 | ||||||||
| FaxNumber: | 3306553828 | ||||||||
| Practice Location | |||||||||
| Address1: | 18697 BAGLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408168770 | ||||||||
| FaxNumber: | 4408168806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 09/03/2009 | ||||||||
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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 | 2085R0202X | 35045848 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35.045848 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000341983 | 01 | OH | BC/BS INDIVIDUAL PIN NO | OTHER | 000000559893 | 01 | OH | ANTHEM | OTHER | 000000234730 | 01 | OH | UNISON | OTHER | 0304914 | 01 | OH | BCMH | OTHER | 0448359 | 05 | OH | MEDICAID | P00600868 | 01 | OH | RAILROAD MEDICARE | OTHER |