Basic Information
Provider Information | |||||||||
NPI: | 1326041559 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIM | ||||||||
FirstName: | KRISTIE | ||||||||
MiddleName: | Y | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8500-8735 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191788735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154567000 | ||||||||
FaxNumber: | 2152542599 | ||||||||
Practice Location | |||||||||
Address1: | 60 TOWNSHIP LINE RD | ||||||||
Address2: |   | ||||||||
City: | ELKINS PARK | ||||||||
State: | PA | ||||||||
PostalCode: | 190272220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2156636677 | ||||||||
FaxNumber: | 2156636265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2005 | ||||||||
LastUpdateDate: | 12/28/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | D44666 | MD | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 171100000X |   |   | N |   | Other Service Providers | Acupuncturist |   | 2081N0008X | D44666 | MD | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Neuromuscular Medicine | 208100000X | MD447500 | PA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | BK3812016 | 01 | MD | DEA # | OTHER | M41097 | 01 | MD | CDS | OTHER | 25MA08727900 | 01 | NJ | NJ | OTHER | D44666 | 01 | MD | MARYLAND LICENSE | OTHER | 312700100 | 05 | MD |   | MEDICAID |