Provider Demographics
NPI:1790729218
Name:NELSON, HAE KYONG KIM (MD)
Entity Type:Individual
Prefix:
First Name:HAE KYONG
Middle Name:KIM
Last Name:NELSON
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A120
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-2670
Practice Address - Fax:864-454-2679
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20480208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3816691OtherCIGNA ID
SC7744166OtherAETNA ID
SC204807Medicaid
SC571004971024OtherBCBS OF SC ID
SC571004971027OtherBLUECHOICE HEALTHPLAN ID
SC370017229OtherRR MEDICARE
SC571004971024OtherBCBS OF SC ID
SC204807Medicaid