MEDICARE: DR. JIN KOO KIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	41404	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467503920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIN KOO KIM MD

Provider Business Mailing Address
First Line	:	6622 N 91ST AVE STE 220
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85305-2569
Country	:	US
Telephone Number	:	602-759-6883
Fax Number	:	602-224-3358

Provider Business Practice Location Address
First Line	:	2580 HIGHWAY 95 STE 224
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7332
Country	:	US
Telephone Number	:	928-763-7722
Fax Number	:	928-763-7744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	02/07/2019

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