MEDICARE: JAE WHAN 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	207P00000X	Emergency Medicine Physician	133905	NY

General Provider Information

NPI Number	:	1407831472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAE WHAN KIM MD

Provider Business Mailing Address
First Line	:	100 HARBOR VIEW DR
Second Line	:	APT 551
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-4700
Country	:	US
Telephone Number	:	516-883-3371
Fax Number	:	516-883-3371

Provider Business Practice Location Address
First Line	:	451 CLARKSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2057
Country	:	US
Telephone Number	:	718-245-3362
Fax Number	:

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

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	07/08/2007

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