Provider Demographics
NPI:1558363119
Name:KIM, KYUNG SOO (MD)
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:SOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:49050 SCHOENHERR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3848
Mailing Address - Country:US
Mailing Address - Phone:586-566-7870
Mailing Address - Fax:586-566-7850
Practice Address - Street 1:14049 E 13 MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-5876
Practice Address - Country:US
Practice Address - Phone:586-415-0103
Practice Address - Fax:586-415-0108
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
MI4301032265207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060-507-4551OtherBLUECROSSBLUESHIELD
MIOH-26467002OtherMEDICARE ID
MIOH-26467002OtherMEDICARE ID
MIAK5563982OtherDEA
MIOH-26467002OtherMEDICARE ID