Provider Demographics
NPI:1467506717
Name:KIM, EDMUND SUNG JOON (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:SUNG JOON
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 1:761 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-513-4000
Mailing Address - Fax:770-995-3495
Practice Address - Street 1:600 PROFESSIONAL DR STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7651
Practice Address - Country:US
Practice Address - Phone:770-513-4000
Practice Address - Fax:770-995-3495
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038273207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000362392LMedicaid
GA000362392LMedicaid
GA160054731OtherPALMETTO GBA RAILROAD
GA746606OtherBLUE CROSS BLUE SHIELD
GA000362392LOtherWELLCARE
GA000362392LMedicaid
GA16BDSWJMedicare ID - Type Unspecified