Provider Demographics
NPI:1710941109
Name:KIM, HAESOOK S (MD)
Entity Type:Individual
Prefix:
First Name:HAESOOK
Middle Name:S
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 2987
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-762-8058
Practice Address - Fax:810-762-8016
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHK0373862085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1410999Medicaid
3208510060OtherBLUE CROSS
3R07601OtherHEALTH PLUS
C1873OtherMCARE
M25510001Medicare ID - Type Unspecified
MI1410999Medicaid