Provider Demographics
NPI:1588647044
Name:KIM, HACK JAE (MD)
Entity Type:Individual
Prefix:
First Name:HACK
Middle Name:JAE
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3707 N 7TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5095
Mailing Address - Country:US
Mailing Address - Phone:480-507-5678
Mailing Address - Fax:480-507-5677
Practice Address - Street 1:2680 S VAL VISTA DR STE 116
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-2154
Practice Address - Country:US
Practice Address - Phone:480-507-5678
Practice Address - Fax:480-507-5677
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32877207RG0100X, 207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ865123Medicaid
AZ865123Medicaid
AZZ136500Medicare PIN