MEDICARE: DR. ICKHEE 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	208600000X	Surgery Physician	2021-02090	NC

General Provider Information

NPI Number	:	1649840919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ICKHEE KIM MD

Provider Business Mailing Address
First Line	:	1215 FAIRFIELD CREEK DR
Second Line	:
City	:	PFAFFTOWN
State	:	NC
Zip	:	27040
Country	:	US
Telephone Number	:	336-918-5384
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-716-2011
Fax Number	:

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

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	06/29/2021

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