Healthcare Provider Details

I. General information

NPI: 1053973578
Provider Name (Legal Business Name): GA HEE KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2019
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 SW INNOVATION WAY
PORT ST LUCIE FL
34987-2111
US

IV. Provider business mailing address

10000 SW INNOVATION WAY
PORT ST LUCIE FL
34987-2111
US

V. Phone/Fax

Practice location:
  • Phone: 772-419-2286
  • Fax: 772-345-8704
Mailing address:
  • Phone: 772-419-2286
  • Fax: 772-345-8704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME180953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: