Provider Demographics
NPI:1770685380
Name:KIM, TAE MOON (MD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:MOON
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 1:100 MEDICAL CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-1259
Mailing Address - Country:US
Mailing Address - Phone:215-361-4623
Mailing Address - Fax:215-361-4922
Practice Address - Street 1:100 MEDICAL CAMPUS DR
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1259
Practice Address - Country:US
Practice Address - Phone:215-368-2100
Practice Address - Fax:215-361-4922
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033329L207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA390012Medicare ID - Type Unspecified
PAC27745Medicare UPIN