MEDICARE: MICHAEL KWANGSOO 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	2086S0122X	Plastic and Reconstructive Surgery Physician	ME78833	FL

General Provider Information

NPI Number	:	1366400590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL KWANGSOO KIM M.D.

Provider Business Mailing Address
First Line	:	3700 CENTRAL AVE
Second Line	:	STE 1
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7649
Country	:	US
Telephone Number	:	239-939-5233
Fax Number	:	239-939-9225

Provider Business Practice Location Address
First Line	:	3700 CENTRAL AVE
Second Line	:	STE 1
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7649
Country	:	US
Telephone Number	:	239-939-5233
Fax Number	:	239-939-9225

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/11/2011

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