Provider Demographics
NPI:1366510992
Name:HONG, IM S (MD)
Entity type:Individual
Prefix:
First Name:IM
Middle Name:S
Last Name:HONG
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 1:211 SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5049
Mailing Address - Country:US
Mailing Address - Phone:573-331-5329
Mailing Address - Fax:573-331-5085
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5329
Practice Address - Fax:573-331-5085
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008030947208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1366510992Medicaid
MO611856OtherANTHEM BCBS
MO959393OtherHEALTHLINK
MO1366510992Medicaid
MO132470008Medicare PIN
MO959393OtherHEALTHLINK