Basic Information
| Provider Information | |||||||||
| NPI: | 1356309009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD | ||||||||
| Address2: | SUITE 6250 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720751 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 3655 LUTHERAN PARKWAY | ||||||||
| Address2: | SUITE #201 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036039800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 04/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 39876 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 39876 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 74434276 | 05 | CO | MEDICAID |