Healthcare Provider Details

I. General information

NPI: 1942715180
Provider Name (Legal Business Name): JAEKEUN KIM MD, PHD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAE KEUN KIM MD, PHD, FACS

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0002
US

IV. Provider business mailing address

101 MONMOUTH ST APT 414
BROOKLINE MA
02446-5612
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-0261
  • Fax:
Mailing address:
  • Phone: 617-935-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number273758
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number283842
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number35.145723
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: