Provider Demographics
NPI:1629244389
Name:KIM, JENNY (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
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:PO BOX 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 ORLEANS ST
Practice Address - Street 2:CRB 1 RM 443
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0013
Practice Address - Country:US
Practice Address - Phone:410-614-3977
Practice Address - Fax:410-614-8160
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2013-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.014085207RH0003X
MDD70993207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD036806700Medicaid
MD036806700Medicaid