MEDICARE: DR. ELLEN M KIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD00046853	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124024229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN M KIM MD

Provider Business Mailing Address
First Line	:	550 GAGE BLVD STE 101
Second Line	:
City	:	RICHLAND
State	:	WA
Zip	:	99352-9532
Country	:	US
Telephone Number	:	509-942-3627
Fax Number	:	509-627-2983

Provider Business Practice Location Address
First Line	:	560 GAGE BLVD STE 206
Second Line	:
City	:	RICHLAND
State	:	WA
Zip	:	99352-8650
Country	:	US
Telephone Number	:	509-942-3286
Fax Number	:	509-628-1354

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	06/13/2022

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