Provider Demographics
NPI:1235218371
Name:KIM, MICHAEL CHANG-BAE (DPT, CHT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHANG-BAE
Last Name:KIM
Suffix:
Gender:M
Credentials:DPT, CHT
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:C
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT, CHT
Mailing Address - Street 1:1132 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6045
Mailing Address - Country:US
Mailing Address - Phone:208-777-7800
Mailing Address - Fax:208-777-9209
Practice Address - Street 1:1132 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-777-7800
Practice Address - Fax:208-777-9209
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1134149941Medicaid
ID1134149941Medicaid