Healthcare Provider Details

I. General information

NPI: 1891011854
Provider Name (Legal Business Name): JOHN KIM MD MED & GERIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 LINWOOD PLAZA #324-325
FORT LEE NJ
07024
US

IV. Provider business mailing address

158 LINWOOD PLAZA #324-325
FORT LEE NJ
07024
US

V. Phone/Fax

Practice location:
  • Phone: 201-944-7300
  • Fax: 201-944-7311
Mailing address:
  • Phone: 201-944-7300
  • Fax: 201-944-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25MA06862000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SOON KIM
Title or Position: OFFICE MANAGER
Credential:
Phone: 201-944-7300