=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538440367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX EYE INSTITUTE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14155 N 83RD AVE SUITE 104
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-5639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-773-3937
-----------------------------------------------------
Fax | 623-773-3955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5609
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85385-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-773-3937
-----------------------------------------------------
Fax | 623-773-3955
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MIN CHEOL KIM
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 623-773-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 36025
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------