Provider Demographics
NPI:1790823466
Name:KANG KIEL KIM MD PC
Entity Type:Organization
Organization Name:KANG KIEL KIM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KANG
Authorized Official - Middle Name:KIEL
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-471-1002
Mailing Address - Street 1:1 WEBSTER AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1361
Mailing Address - Country:US
Mailing Address - Phone:845-471-1002
Mailing Address - Fax:845-471-1003
Practice Address - Street 1:1 WEBSTER AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1361
Practice Address - Country:US
Practice Address - Phone:845-471-1002
Practice Address - Fax:845-471-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111678208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00538156Medicaid
NY00538156Medicaid
NYC07807Medicare UPIN