Provider Demographics
NPI:1356671861
Name:CHIN SE KIM, MD INC
Entity Type:Organization
Organization Name:CHIN SE KIM, MD INC
Other - Org Name:MERIDIAN SPORTS MEDICINE & PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIN
Authorized Official - Middle Name:SE
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-520-0809
Mailing Address - Street 1:1736 W MEDICAL CENTER DR STE B
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1854
Mailing Address - Country:US
Mailing Address - Phone:714-520-0809
Mailing Address - Fax:714-520-0835
Practice Address - Street 1:1736 W MEDICAL CENTER DR STE B
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1854
Practice Address - Country:US
Practice Address - Phone:714-520-0809
Practice Address - Fax:714-520-0835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46079207RS0010X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE48498Medicare UPIN