Healthcare Provider Details

I. General information

NPI: 1457351702
Provider Name (Legal Business Name): SEONG CHEOL KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 11/17/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 MEADOWWEDGE LOOP
ST CLOUD FL
34772
US

IV. Provider business mailing address

2647 MEADOWWEDGE LOOP
ST CLOUD FL
34772
US

V. Phone/Fax

Practice location:
  • Phone: 407-793-4608
  • Fax: 269-651-1411
Mailing address:
  • Phone: 407-793-4608
  • Fax: 269-651-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number039276
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberSK039276
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301039276
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number039276
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: