Basic Information
Provider Information | |||||||||
NPI: | 1760413272 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIM | ||||||||
FirstName: | KOK | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 N SHADELAND AVE | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462194959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5177 MCCARTY LN | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479058764 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179231787 | ||||||||
FaxNumber: | 3179620853 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 06/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 35061850L | OH | N |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   | 208G00000X | 01084540A | IN | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | P0011966 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000039033 | 01 | OH | ANTHEM | OTHER | 0851065 | 05 | OH |   | MEDICAID |