Healthcare Provider Details

I. General information

NPI: 1336381185
Provider Name (Legal Business Name): PETER KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

IV. Provider business mailing address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

V. Phone/Fax

Practice location:
  • Phone: 651-325-2307
  • Fax: 651-229-1713
Mailing address:
  • Phone: 651-325-2307
  • Fax: 651-229-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number54156
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: