Provider Demographics
NPI:1689808214
Name:KIM, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:KIM
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 1:61 WHITCHER ST NE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1176
Mailing Address - Country:US
Mailing Address - Phone:770-422-3290
Mailing Address - Fax:770-422-0287
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 1100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:770-422-3290
Practice Address - Fax:770-422-0287
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA063362207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA939355713CMedicaid
GA939355713AMedicaid
GA939355713BMedicaid
GAP00874274OtherMEDICARE RAILROAD
GA202I204612Medicare PIN