Provider Demographics
NPI:1629239256
Name:MCKIM, STEPHEN ERNEST (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ERNEST
Last Name:MCKIM
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 1:9735 KINCEY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-9118
Mailing Address - Country:US
Mailing Address - Phone:704-414-2870
Mailing Address - Fax:704-414-2860
Practice Address - Street 1:12610 N COMMUNITY HOUSE RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3892
Practice Address - Country:US
Practice Address - Phone:704-752-3730
Practice Address - Fax:704-752-9056
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36486208800000X
NC2013-00734208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2277Medicaid
SCNC2277Medicaid
NCNCE187AMedicare PIN