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General NPI Number Information
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NPI Number | 1790899755
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Entity Type | Individual
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Provider Name | JAE SUK KIM MD
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Gender | Male
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 24025 GREATER MACK SUITE 103
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City | ST CLAIR SHORES
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State | MI
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Zip | 48080
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Country | US
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Telephone | 586-777-8280
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Fax | 586-777-8688
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Provider Business Mailing Address
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Address Line | 24025 GREATER MACK SUITE 103
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City | ST CLAIR SHORES
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State | MI
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Zip | 48080
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Country | US
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Telephone | 586-777-8280
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Fax | 586-777-8688
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 4301033045
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License Number State | MI
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