Provider Demographics
NPI:1790726537
Name:KIM, KYUNGMI (MD)
Entity Type:Individual
Prefix:DR
First Name:KYUNGMI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KYUNGMI
Other - Middle Name:KIM
Other - Last Name:SUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12745 S SAGINAW ST
Mailing Address - Street 2:806-196
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2437
Mailing Address - Country:US
Mailing Address - Phone:248-691-8646
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-691-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA66347207R00000X
MI4301108670208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M88530OtherMEDICARE
NJ7395108Medicaid
NJ0358979000OtherAMERIHEALTH
NJG59264Medicare UPIN
NJG59264Medicare UPIN