Provider Demographics
NPI:1316100480
Name:KIM, SOO (MD)
Entity type:Individual
Prefix:DR
First Name:SOO
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF ANESTHESIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8700
Mailing Address - Fax:414-259-1522
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:414-259-1522
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2012-01074207L00000X
WI62215207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316100480Medicaid
WI1316100480Medicaid