MEDICARE: DR. GWANG OCH 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	207RN0300X	Nephrology Physician	35 040705	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	390007082	OTHER	OH	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	000000129590	OTHER	OH	ANTHEM BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992706543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWANG OCH KIM MD

Provider Business Mailing Address
First Line	:	1031 PIERCE STREET
Second Line	:	SUITE D
City	:	SANDUSKY
State	:	OH
Zip	:	44870
Country	:	US
Telephone Number	:	419-557-5541
Fax Number	:	419-557-5542

Provider Business Practice Location Address
First Line	:	2819 HAYES AVE
Second Line	:	SUITE #1
City	:	SANDUSKY
State	:	OH
Zip	:	44870-5391
Country	:	US
Telephone Number	:	419-627-8403
Fax Number	:	419-627-1962

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

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	09/12/2012

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