MEDICARE: TAE HYUN KIM DPM INC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	E4262	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E4262	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1295967719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAE HYUN KIM DPM INC

Provider Business Mailing Address
First Line	:	13701 BURBANK BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-5040
Country	:	US
Telephone Number	:	818-997-1216
Fax Number	:	818-997-4458

Provider Business Practice Location Address
First Line	:	13701 BURBANK BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-5040
Country	:	US
Telephone Number	:	818-997-1216
Fax Number	:	818-997-4458

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TAE H KIM
Credential	:	D.P.M.
Telephone Number	:	818-997-1216

Provider Enumeration Date	:	08/17/2009
Last Update Date	:	11/02/2009

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