Provider Demographics
NPI:1548258379
Name:KIM, SUSIE C (MD)
Entity type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:C
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:STE 130
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7306
Mailing Address - Country:US
Mailing Address - Phone:970-247-1120
Mailing Address - Fax:970-247-1128
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE 130
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-247-1120
Practice Address - Fax:970-247-1128
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2022-09-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO41867207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1982948089Medicaid
NE10026280800Medicaid
NE10026280600Medicaid
NE10026281000Medicaid
KS201038550AMedicaid
CO57723834Medicaid
NE10026280700Medicaid
NE10026281200Medicaid
NE10026283100Medicaid
NE10026280600Medicaid
COC510538Medicare PIN
NENA2301004Medicare PIN
COH08377Medicare UPIN
NE10026281200Medicaid