Healthcare Provider Details

I. General information

NPI: 1205980208
Provider Name (Legal Business Name): CHRISTOPHER KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD NEONATAL INTENSIVE CARE UNIT
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

1929 CROSSWAY DRIVE
FORT WAYNE IN
46814
US

V. Phone/Fax

Practice location:
  • Phone: 260-639-3795
  • Fax: 260-639-3795
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01053983A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: