Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | MD 434999 | PA |
NPI | 1053553487 |
---|---|
Provider Name | Dr. Bong-Soo Kim |
First Address | Philadelphia, PA 19129-1302 |
Second Address | Philadelphia, PA 19140-4105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2009 |
Last Update Date | 01/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1063553498 | 1063553498 (01) | PA |