Provider Demographics
NPI:1124024229
Name:KIM, ELLEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:560 GAGE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-8650
Practice Address - Country:US
Practice Address - Phone:509-942-3286
Practice Address - Fax:509-628-1354
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046853207R00000X
PAMD419016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8458986Medicaid
WA8458986Medicaid
WAG8861143Medicare PIN
WAH71373Medicare UPIN
PA063184Medicare ID - Type Unspecified