NPIMap

Organization Active NPI

Myung-Sup Kim MD PA

  • Specialist
  • Petersburg, WV
National Provider Identifier
1457311656
Registry record updated Aug 16, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
MYUNG-SUP KIM MD PA
Practice address
RT 55 West
Petersburg, WV 26847
Phone
(304) 257-1026
NPI assigned
Mar 23, 2006
Last updated
Aug 16, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 16, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Myung-Sup Kim, MDNPI 1306849492
Title
President
Phone
(301) 724-1646

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X Primary

Addresses

Primary practice location

RT 55 West
Petersburg, WV 26847

Mailing address

PO Box 240
Cumberland, MD 21501-0240
Phone (301) 724-1646

Other identifiers 7

IdentifierTypeStateIssuer
3810011406MedicaidWV
991702100MedicaidMD
S366OtherMDFEDERAL BS
02059300OtherBLACK LUNG
001708869OtherWVBLUE SHIELD
1120362OtherMAMSI
KCD4OtherMDBLUE SHIELD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV, MD, VA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20041029000524 WV Part B Supplier - Clinic/Group Practice 9739141078 Receives reassigned benefits from 1 practitioner
Practice locations: Petersburg, WV
O20050405000224 MD Part B Supplier - Clinic/Group Practice 9739141078 Receives reassigned benefits from 1 practitioner
Practice locations: Cumberland, MD
O20120612000451 VA Part B Supplier - Clinic/Group Practice 9739141078 Receives reassigned benefits from 1 practitioner
Practice locations: Leesburg, VA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1143072000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1281916800000",
    "number": "1457311656",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 240",
            "city": "CUMBERLAND",
            "state": "MD",
            "postal_code": "215010240",
            "telephone_number": "301-724-1646",
            "fax_number": "301-724-7429"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "RT 55 WEST",
            "city": "PETERSBURG",
            "state": "WV",
            "postal_code": "26847",
            "telephone_number": "304-257-1026"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MYUNG-SUP KIM MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-23",
        "last_updated": "2010-08-16",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "MYUNG-SUP",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "301-724-1646",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3810011406",
            "state": "WV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "991702100",
            "state": "MD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FEDERAL BS",
            "identifier": "S366",
            "state": "MD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLACK LUNG",
            "identifier": "02059300",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "001708869",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAMSI",
            "identifier": "1120362",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "KCD4",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Petersburg, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 16, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.