Basic Information
| Provider Information | |||||||||
| NPI: | 1568516466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | HUMPHREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1329 SW 16TH ST RM 2232 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527330485 | ||||||||
| FaxNumber: | 3522658077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326101288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527330485 | ||||||||
| FaxNumber: | 3522658077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D0045080 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME132190 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P00654786 | 01 | MD | RAILROAD MEDICARE | OTHER | 107975600 | 05 | FL | MEDICAID | 310010300 | 05 | MD | MEDICAID |