MEDICARE: JAE KOUL 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	2085R0202X	Diagnostic Radiology Physician	32890	AZ
2	2085U0001X	Diagnostic Ultrasound Physician	32890	AZ
3	2085B0100X	Body Imaging Physician	32890	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CS7943	OTHER	AZ	GROUP MEDICARE RAILROAD ID & PTAN
3	ZWCBBM	OTHER	AZ	GROUP MEDICARE ID
7	P00109556	OTHER	AZ	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124099213	OTHER	AZ	PHYSICIAN INDIVIDUAL NPI
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1841261989	OTHER	AZ	GROUP NPI
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124099213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAE KOUL KIM MD

Provider Business Mailing Address
First Line	:	4729 E SUNRISE DR # 315
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-4534
Country	:	US
Telephone Number	:	520-429-2023
Fax Number	:

Provider Business Practice Location Address
First Line	:	4729 E SUNRISE DR # 315
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-4534
Country	:	US
Telephone Number	:	520-429-2023
Fax Number	:

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

Provider Enumeration Date	:	01/28/2006
Last Update Date	:	11/09/2016

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Directions to “ JAE KOUL KIM MD” Practice Location

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