Provider Demographics
NPI:1194738500
Name:DUCK J KIM MD PC
Entity type:Organization
Organization Name:DUCK J KIM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUCK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-563-8050
Mailing Address - Street 1:210 CORNELIA ST
Mailing Address - Street 2:STE 204
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2396
Mailing Address - Country:US
Mailing Address - Phone:518-563-8050
Mailing Address - Fax:518-563-8352
Practice Address - Street 1:210 CORNELIA ST
Practice Address - Street 2:STE 204
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2396
Practice Address - Country:US
Practice Address - Phone:518-563-8050
Practice Address - Fax:518-563-8352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2011-03-09
Deactivation Date:2007-12-17
Deactivation Code:
Reactivation Date:2011-03-09
Provider Licenses
StateLicense IDTaxonomies
NY110604207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00511922Medicaid
NY000405443001OtherBLUE SHIELD NORTHEASTERN
NY000405443001OtherBLUE SHIELD NORTHEASTERN
D01814Medicare UPIN
30726BMedicare ID - Type Unspecified