Healthcare Provider Details

I. General information

NPI: 1457303372
Provider Name (Legal Business Name): EDSEL U. KIM, M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY SUITE 607
PORTLAND OR
97210
US

IV. Provider business mailing address

2222 NW LOVEJOY SUITE 607
PORTLAND OR
97210
US

V. Phone/Fax

Practice location:
  • Phone: 503-222-3638
  • Fax: 503-223-5139
Mailing address:
  • Phone: 503-222-3638
  • Fax: 503-223-5139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD24541
License Number StateOR

VIII. Authorized Official

Name: DR. EDSEL U. KIM
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 503-222-3638