Provider Demographics
NPI:1760599807
Name:KIM, S JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:S
Middle Name:JOHN
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 1:10555 W PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2000
Mailing Address - Country:US
Mailing Address - Phone:414-427-5200
Mailing Address - Fax:414-427-5205
Practice Address - Street 1:10555 W PARNELL AVE
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2000
Practice Address - Country:US
Practice Address - Phone:414-427-5200
Practice Address - Fax:414-427-5205
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25060-0202084P0800X
IA231812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30565800Medicaid
WI30565800Medicaid
WIB54130Medicare UPIN