Provider Demographics
NPI:1417382821
Name:KIM, HYUNG T (MD)
Entity Type:Individual
Prefix:
First Name:HYUNG
Middle Name:T
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 1:801 PLYMOUTH AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-6555
Mailing Address - Country:US
Mailing Address - Phone:314-255-9255
Mailing Address - Fax:
Practice Address - Street 1:655 KENMOOR AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-363-7690
Practice Address - Fax:616-942-8917
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001489208D00000X
MI4301059422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice