Provider Demographics
NPI:1730204421
Name:SOO R KIM MD PC
Entity type:Organization
Organization Name:SOO R KIM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SOO
Authorized Official - Middle Name:R
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-343-5970
Mailing Address - Street 1:29 WEST ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126
Mailing Address - Country:US
Mailing Address - Phone:315-343-5970
Mailing Address - Fax:315-343-3739
Practice Address - Street 1:29 WEST ONEIDA ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-343-5970
Practice Address - Fax:315-343-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851475958OtherCURRENT NPI#
NY00758076Medicaid
1851475958OtherCURRENT NPI#
D02229Medicare UPIN