Jeffrey Jisung Kim, PT DPT – Physical Therapist

Key facts

NPI: 1073197984
Entity type: Individual (NPI type 1)
Primary specialty: Physical Therapist 225100000X
License: 1345176 (TX)
Practice address: 3700 Cross Park Dr
Bryan, TX 77802-4137
Phone: (979) 774-9958
Fax: (979) 774-9978
NPI assigned: May 6, 2021
Sex: Male
Sole proprietor: No

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Advance Therapy PC Physical Medicine & Rehabilitation Physician · Bryan, TX · NPI 1710187737

Medicare reassignment Care Compare group NPD PHYSICAL THERAPIST · TX
Advance Therapy PC Physical Therapist · Bryan, TX · NPI 1629522818

NPD (past) PHYSICAL THERAPIST

Medicare Care Compare profile

Specialty: Physical Therapist in Private Practice
Education: Other, 2020
Medicare assignment: Accepts the Medicare-approved amount as payment in full
Group practices: Advance Therapy, PC (14 clinicians)

Practice addresses (Care Compare)

3700 Cross Park Dr
Bryan, TX 77802-4137
Phone (979) 774-9958

Merit-based Incentive Payment System (MIPS)

Final score: 75 of 100 (individual)

Medicare participation

Medicare fee-for-service enrollment: Enrolled in TX

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20210727002672	TX	Practitioner - Physical Therapist in Private Practice	3173926250	Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD): Yes

State licenses

License	State	Type	Specialty
1345176	TX	MD	Physical Therapist

Practice roles

Organization	Specialty	Status	New patients
Advance Therapy PC	Physical Therapist	Current since May 6, 2021	Accepting new patients
Advance Therapy PC	Physical Therapist	Past since May 6, 2021	Accepting new patients

Locations

3700 Cross Park Dr
Bryan, TX 77802
Phone (979) 774-9958

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Physical Therapist	225100000X	1345176	TX	Yes

Addresses

Primary practice location

3700 Cross Park Dr
Bryan, TX 77802-4137

Mailing address

3700 Cross Park Dr
Bryan, TX 77802-4137
Phone (979) 774-9958

Other identifiers

Identifier	Type	State	Issuer
1345176	Other	TX	PHYSICAL THERAPY LICENSE

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on May 7, 2021.

{
    "created_epoch": "1620259200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620345600000",
    "number": "1073197984",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3700 CROSS PARK DR",
            "city": "BRYAN",
            "state": "TX",
            "postal_code": "778024137",
            "telephone_number": "979-774-9958",
            "fax_number": "979-774-9978"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3700 CROSS PARK DR",
            "city": "BRYAN",
            "state": "TX",
            "postal_code": "778024137",
            "telephone_number": "979-774-9958",
            "fax_number": "979-774-9978"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KIM",
        "first_name": "JEFFREY",
        "middle_name": "JISUNG",
        "credential": "PT DPT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-05-06",
        "last_updated": "2021-05-07",
        "certification_date": "2021-05-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "TX",
            "license": "1345176",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHYSICAL THERAPY LICENSE",
            "identifier": "1345176",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bryan, TX

All providers in Bryan, TX · Physical Therapist in Texas

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 7, 2021. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.