1124024229 NPI number — DR. ELLEN M KIM MD

Table of content: DR. ELLEN M KIM MD (NPI 1124024229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124024229 NPI number — DR. ELLEN M KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
ELLEN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124024229
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 GAGE BLVD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99352-9532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-942-3627
Provider Business Mailing Address Fax Number:
509-627-2983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 GAGE BLVD STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99352-8650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-942-3286
Provider Business Practice Location Address Fax Number:
509-628-1354
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD00046853 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8458986 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com