MEDICARE: JAE KIM M.D., PH.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	207R00000X	Internal Medicine Physician	91319	GA

General Provider Information

NPI Number	:	1780079905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAE KIM M.D., PH.D.

Provider Business Mailing Address
First Line	:	201 ABRAHAM FLEXNER WAY STE 600
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-3841
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3970 DEPUTY BILL CANTRELL MEM
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-3069
Country	:	US
Telephone Number	:	678-513-2273
Fax Number	:	678-513-8869

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

Provider Enumeration Date	:	04/03/2015
Last Update Date	:	06/20/2024

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