Provider Demographics
NPI:1275538076
Name:KIM, EDWARD C (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:C
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 1:8640 SUDLEY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4404
Mailing Address - Country:US
Mailing Address - Phone:703-368-6819
Mailing Address - Fax:703-330-2923
Practice Address - Street 1:8640 SUDLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4404
Practice Address - Country:US
Practice Address - Phone:703-368-6819
Practice Address - Fax:703-330-2923
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045874207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005847052Medicaid
VA2431908OtherAETNA HMO
VA284691OtherMAMSI
VA7206160OtherAETNA PPO
VA92130005OtherCAREFIRST
VA317528OtherANTHEM/WARRENTON
VA3781769003OtherCIGNA
VA317527OtherANTHEM/MANASSAS
VA541604636OtherVIRGINIA HEALTH NETWORK
VA100000273Medicare ID - Type Unspecified
VA005847052Medicaid