Provider Demographics
NPI:1629386388
Name:KIM, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:KIM SUH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11731 POINTE PL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4636
Mailing Address - Country:US
Mailing Address - Phone:770-284-3150
Mailing Address - Fax:
Practice Address - Street 1:601 OLD NORCROSS RD STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4311
Practice Address - Country:US
Practice Address - Phone:770-284-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96652207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012351100Medicaid
FLP01366451OtherRAILROAD MEDICARE
FLHU997ZMedicare PIN