MEDICARE: GRACE S 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	207LP2900X	Pain Medicine (Anesthesiology) Physician	050970	GA
2	207LP3000X	Pediatric Anesthesiology Physician	050970	GA
3	208VP0000X	Pain Medicine Physician	050970	GA
4	208VP0014X	Interventional Pain Medicine Physician	050970	GA
5	207L00000X	Anesthesiology Physician	050970	GA

General Provider Information

NPI Number	:	1841285095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE S KIM MD

Provider Business Mailing Address
First Line	:	531 ROSELANE ST NW STE 830
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-6979
Country	:	US
Telephone Number	:	770-794-0477
Fax Number	:	770-794-3108

Provider Business Practice Location Address
First Line	:	677 CHURCH ST NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1101
Country	:	US
Telephone Number	:	770-794-0477
Fax Number	:	770-794-3108

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	08/27/2019

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Directions to “ GRACE S KIM MD” Practice Location

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