Provider Demographics
NPI:1154363109
Name:KIM, ANTHONY H (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:H
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 STATE ROUTE 22B
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-3417
Mailing Address - Country:US
Mailing Address - Phone:518-563-8000
Mailing Address - Fax:518-563-9001
Practice Address - Street 1:2155 STATE ROUTE 22B
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-3417
Practice Address - Country:US
Practice Address - Phone:518-563-8000
Practice Address - Fax:518-563-9001
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1659642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01561004Medicaid
NY55401BMedicare ID - Type Unspecified
NYE74693Medicare UPIN