Provider Demographics
NPI:1578597282
Name:KIM, MARK M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
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 1:301 ST. PAUL PLACE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7927 RITCHIE HWY.
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-761-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054574207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2197875OtherAETNA
MDS190 / 0009OtherBLUE CHOICE
MDKF68 / 607687-01, 02OtherBC/BS OF MD
MD730901500Medicaid
MDS190 / 0009OtherBLUE CHOICE
MDG95217Medicare UPIN