MEDICARE: CHARLES S. KIM M.D.

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	174400000X	Specialist	41236	TN
2	208100000X	Physical Medicine & Rehabilitation Physician	41236	TN
3	208100000X	Physical Medicine & Rehabilitation Physician	57253	MN

General Provider Information

NPI Number	:	1154361434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES S. KIM M.D.

Provider Business Mailing Address
First Line	:	PO BOX 11839
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55111-0839
Country	:	US
Telephone Number	:	984-377-3422
Fax Number	:	855-740-1940

Provider Business Practice Location Address
First Line	:	631 CLEVELAND AVE S STE 5
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1244
Country	:	US
Telephone Number	:	984-377-3422
Fax Number	:

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	03/17/2018

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