Healthcare Provider Details

I. General information

NPI: 1700854411
Provider Name (Legal Business Name): CHARLES K KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15290 PENNOCK LN MAIL STOP 32200A
APPLE VALLEY MN
55124-7163
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-8500
  • Fax: 952-431-6966
Mailing address:
  • Phone: 952-883-5790
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48293
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: