Provider Demographics
NPI:1710381660
Name:KENNETH J KIM, M.D., P.C.
Entity Type:Organization
Organization Name:KENNETH J KIM, M.D., P.C.
Other - Org Name:KENNETH J KIM PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-246-0022
Mailing Address - Street 1:3930 PENDER DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0985
Mailing Address - Country:US
Mailing Address - Phone:703-246-0022
Mailing Address - Fax:703-246-0080
Practice Address - Street 1:3930 PENDER DR
Practice Address - Street 2:SUITE 330
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0985
Practice Address - Country:US
Practice Address - Phone:703-246-0022
Practice Address - Fax:703-246-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245549261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care