Provider Demographics
NPI:1275605743
Name:KAPOLEI FAMILY MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:KAPOLEI FAMILY MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-674-2930
Mailing Address - Street 1:590 FARRINGTON HWY
Mailing Address - Street 2:SUITE 526A
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2009
Mailing Address - Country:US
Mailing Address - Phone:808-674-2930
Mailing Address - Fax:
Practice Address - Street 1:590 FARRINGTON HWY
Practice Address - Street 2:SUITE 526A
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2009
Practice Address - Country:US
Practice Address - Phone:808-674-2930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12184207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI50100815Medicaid
HI52141018Medicaid
HIH55656OtherMEDICARE ID PTAN GROUP
HIH55656OtherMEDICARE ID PTAN GROUP
HIH41265Medicare UPIN
HI52141018Medicaid
HI50100815Medicaid