Provider Demographics
NPI:1306849492
Name:KIM, MYUNG-SUP (MD)
Entity type:Individual
Prefix:DR
First Name:MYUNG-SUP
Middle Name:
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:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-0808
Mailing Address - Country:US
Mailing Address - Phone:301-724-1646
Mailing Address - Fax:301-724-7429
Practice Address - Street 1:952 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1950
Practice Address - Country:US
Practice Address - Phone:301-777-3522
Practice Address - Fax:301-777-1902
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26261174400000X, 2085B0100X, 2085D0003X, 2085N0700X, 2085N0904X, 2085R0204X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ2480003OtherGHMSI
WV2001896000Medicaid
WV0117502000Medicaid
MD526991100Medicaid
MDS3660001OtherGHMSI
PA0010496230Medicaid
WV001708869OtherMT ST BLUE SHIELD
MDJ2490003OtherGHMSI
D77888Medicare UPIN
PA0010496230Medicaid
300130075Medicare PIN
300129038Medicare PIN
MDS3660001OtherGHMSI
MD321FMedicare ID - Type Unspecified
WV001708869OtherMT ST BLUE SHIELD
MD299FMedicare ID - Type Unspecified