Provider Demographics
NPI:1629155205
Name:HOR, KEM SU (MD)
Entity Type:Individual
Prefix:
First Name:KEM
Middle Name:SU
Last Name:HOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 15497
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80935-5497
Mailing Address - Country:US
Mailing Address - Phone:719-473-4030
Mailing Address - Fax:
Practice Address - Street 1:160 W FILLMORE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6155
Practice Address - Country:US
Practice Address - Phone:719-636-1299
Practice Address - Fax:719-636-9166
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39335207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COHOA65018OtherBLUE SHIELD
CO83836870Medicaid
CO83836870Medicaid
COHOA65018OtherBLUE SHIELD
CO83836870Medicaid