Healthcare Provider Details

I. General information

NPI: 1356671861
Provider Name (Legal Business Name): CHIN SE KIM, MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 W MEDICAL CENTER DR STE B
ANAHEIM CA
92801-1854
US

IV. Provider business mailing address

1736 W MEDICAL CENTER DR STE B
ANAHEIM CA
92801-1854
US

V. Phone/Fax

Practice location:
  • Phone: 714-520-0809
  • Fax: 714-520-0835
Mailing address:
  • Phone: 714-520-0809
  • Fax: 714-520-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberA46079
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA46079
License Number StateCA

VIII. Authorized Official

Name: DR. CHIN SE KIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-520-0809