Healthcare Provider Details

I. General information

NPI: 1083960447
Provider Name (Legal Business Name): TAIK KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11731 POINTE PL
ROSWELL GA
30076-4636
US

IV. Provider business mailing address

11731 POINTE PL
ROSWELL GA
30076-4636
US

V. Phone/Fax

Practice location:
  • Phone: 770-284-3150
  • Fax: 770-284-3170
Mailing address:
  • Phone: 770-284-3150
  • Fax: 770-284-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD462403
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number83789
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: