Basic Information
| Provider Information | |||||||||
| NPI: | 1396737359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | TAE | ||||||||
| MiddleName: | WHANG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6720 BERTNER AVE | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323552666 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6720 BERTNER AVE | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323552666 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D45782 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 57798 | MN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | K6627 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 106121003 | 05 | TX | MEDICAID | 418065800 | 05 | MD | MEDICAID |