Provider Demographics
NPI:1568575884
Name:KIM, ANN (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 BRIDLE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-2261
Mailing Address - Country:US
Mailing Address - Phone:302-475-1730
Mailing Address - Fax:
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 3302
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-623-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10007722208100000X
PAMD4254352081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1568575884Medicaid
DE1568575884Medicaid