MEDICARE: CARECONNECTMD WISCONSIN PROFESSIONAL CORPORATION

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1619658176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARECONNECTMD WISCONSIN PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	3090 BRISTOL ST STE 200
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-3061
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 QUINN DR FL 1
Second Line	:
City	:	WAUNAKEE
State	:	WI
Zip	:	53597-2502
Country	:	US
Telephone Number	:	888-789-9585
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HYONG KIM
Credential	:	MD
Telephone Number	:	888-789-9585

Provider Enumeration Date	:	07/27/2023
Last Update Date	:	11/20/2025

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