Provider Demographics
NPI:1063447845
Name:KIM, TAE H (MD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:H
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 VREDENBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-2134
Mailing Address - Country:US
Mailing Address - Phone:914-237-5430
Mailing Address - Fax:914-237-2667
Practice Address - Street 1:135 VREDENBURGH AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-2134
Practice Address - Country:US
Practice Address - Phone:914-237-5430
Practice Address - Fax:914-237-2667
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150184207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00712336Medicaid
NY70A121Medicare ID - Type Unspecified
NYC11954Medicare UPIN