Basic Information
| Provider Information | |||||||||
| NPI: | 1992967293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | JOOWHAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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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 | 2085R0202X | 01066145A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 01066145A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01066145A | 01 | IN | IN LICENSE | OTHER | 20139730 | 05 | IN | MEDICAID |