Healthcare Provider Details

I. General information

NPI: 1790729218
Provider Name (Legal Business Name): HAE KYONG KIM NELSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE A120
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-2670
  • Fax: 864-454-2679
Mailing address:
  • Phone: 864-797-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20480
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: